ABSTRACT
Introduction: The crisis connected with Covid-19 has had strong economic and social repercussions. However, during the state of emergency with restricted access to healthcare, healthcare institutions and users have tested the potential of dematerialization of services thanks to digitalization. The PNRR have maintained in the health sector (Mission6 Health) a fixed point on the horizontal strategic axis of digitalization and innovation, focusing on proximity networks, intermediate structures, telemedicine for territorial health care (Community Homes and Community Hospitals) and on the research and digitalization of the NHS (Electronic Health Record and Essential Levels of Assistance).Our proposal identifies an integrated path that, with the active participation of professionals from the Hospital, the Territory, GPs, social services and families, it allows an appropriate and rapid taking in charge of the patient in hospital discharge Methods: From the SDO office with the Quany we found some indicators of Intensive Cardiology: average weight of ordinary DRG (1.8vs2), average hospital stay (9.05vs9.42), rotation index of beds (51vs39) and pertinence of hospitalizations for acute care / mean hospitalization (9.48 vs 9.38) respectively of 2019-2020 in order to be able to identify critical issues and solutions in the pathways of the frail and improve performance.We used the BPI technique by implementing the Electronic Medical Record and integrating modules that can facilitate a protected discharge by reducing the fragmentation of assistance between the different healthcare structures.We have evaluated the medical-legal questions and identified indicators (average time between arrival of the request and evaluation by the figures involved in the Protected Discharge, time average between evaluation and admission to RSA / Intermediate Care, number of patients discharged with treatment on territory. Expected Results: The mapping of the revised process by sharing informations (patient's condition and social context), determines the most appropriate post-discharge intervention setting while containing costs.Conclusion The process of taking charge of the territory allowing for benchmarking and control of the quality levels of the care provided.