UN MODELLO DI RETE PER LA GESTIONE INTEGRATA DELLA PATOLOGIA DIABETICA

A network care model for the management of diabetic patients A feasibility study (approved for funding by the Italian Ministry of Health) has been designed to evaluate an innovative care model for diabetes, based on the Outpatient Day Service (ODS), in term of quality of healthcare, compliance, social and health costs and patient's quality of life and satisfaction. We enrolled eight Diabetes Unit of major regional hospitals. ODS has been defined as an innovative health care modality, which is part of the specialist ambulatory service operating at the territorial level and is aimed at the management of clinical conditions. It requires numerous, multidisciplinary and often complex laboratory and instrumental procedures as defined by a specific diagnostic and therapeutic path centred on the clinical problem, rather than on the individual procedure. ODS includes a basic package and packages for micro and macro vascular chronic complications. It has been investigated the feasibility to insert a "Clinical Pathway" for diabetic patients into the Local Health Authority database SISS (Sistema Informativo Socio Sanitario, Health and Social Informative System), as an Electronic Health Record (EHR) service. The EHR is a virtual healthcare repository that gathers all the citizen's information and clinical documents produced by doctors and health professionals, making them available even when they are produced in different institutes. The Clinical Pathway has been organized as a "virtual folder". The term "folder" expresses the concept of a binder issued to the patient for the specific pathology (in this case diabetes), used to gather structured documents; the term "virtual" describes that the folder filling is shared amongst the different actors that collaborate on the pathway. The clinical pathway implementation is essentially made as a clinical documents collection that belongs to the same subject. Additionally aim of the study is to evaluate whether sharing of a minimum data set across the levels of care can improve the integration between primary and secondary care. Structure indicators, Process indicators, Outcomes, Therapy indicators, Costs, Quality of life and patient satisfaction have been created. A preliminary analysis of the database has been carried out for evaluate data quality and the effective possibility of obtain the indicators. Project help the systematic management of diabetic patients by General Practitioner (primary care) and hospital diabetes facilities and improve integration between first and second care levels.