Managing transition to ValueēBased hospital care pathways

Issue San Raffaele Hospital (OSR) is part of a European alliance of 9 University Hospitals (EUHA) which promotes comparison and excellence in the clinical, research and training strategies. Description of the Problem The development of Value-Based (VB) strategies has been active in OSR since March 2019, with multidisciplinary healthcare pathways and with the promotion of patient engagement. Results The prostate cancer pathway was identified as a pilot and replicable model to promote the VB culture in different areas, in particular in the field of digitalization, human resources, research, redesigning of paths and outcomes collection. The other clinical pathways progressively launched during 2019 were: breast cancer, stroke, heart failure and pancreatic cancer. The project was realized by: • setting up a Multidisciplinary disease teams; developing a training course on VB, involving all the healthcare professionals (clinicians and managers);involving patient associations in the development of the pathway;adopting sets of clinical outcomes, Patient-Related Outcome Measures (PROMs) and Patient-Related Experience Measures (PREMs) with a specific collection platform, currently under implementation;identifying new IT support tools, activated from March to December 2019 in 11 Disease Units: HealthMeeting, a platform supporting document and data sharing, connecting different Specialists and performing advanced digital multidisciplinary meetings; DNM-Digital Narrative Medicine, a platform connecting patients with their clinical team, supporting web-based storytelling and personalized therapeutic approach. Lessons The introduction of a new shared and patient-centred work model, with the reorganization of spaces, resources and dedicated IT tools, has improved the diagnostic-therapeutic process. Key messages The main challenge of hospital transition to VB pathways is organizational and cultural. For VB implementation is needed sustainable use of available resources and IT, to achieve better outcomes.

Hospital transition care for the elderly: an integrative review

ABSTRACT Objective: to identify evidence of scientific production on hospital transition care provided to the elderly. Method: an integrative review, with publications search in the MEDLINE, PubMed, LILACS, BDENF, Index Psychology and SciELO databases, with keywords and Mesh terms: elderly, hospitalization, patient discharge, health of the elderly, and transitional care, between 2013 and 2017 in English, Portuguese and Spanish. The 14 selected articles analysis was carried out through exploratory and critical reading of titles, abstracts and results of the researches. Results: transitional care can prevent re-hospitalizations as they enable rehabilitation, promotion and cure of illnesses in the elderly. Final considerations: transitional care implies the improvement of the quality of life of the elderly person, requiring skilled health professionals who involve the family through accessible communication.