The COVID-19 epidemic highlighted various flaws in the organisational care models. The Italian National Healthcare System (SSN) suddenly had to face an emergency situation that forced it to make certain changes- later found to be necessary and indispensible- to meet the needs generated by the pandemic. The most significant changes concerned- and still concern- the local provision of healthcare services.
There were various types and qualities of responses to the emergency; they were also disconnected from one another due to the rapid progression of the epidemic and the general lack of preparedness. Even though they were activated without being evidence or experience-based some of them now constitute an asset, also for the future. They are, in fact, examples of good practice in the healthcare sector and a new resource for our country to employ when making needed improvements in terms of efficacy, efficiency and equal accessibility to local service provision. This potential enhancement in the quality of our healthcare should not be missed and should actually be integrated into the system so that we can avoid any reductionist approach and going back to the pre-epidemic situation.
During the epidemic the local healthcare provision of services found new significance. Two main issues led to the change of the procedures governing local healthcare provision: the overload of healthcare facilities and the distancing requirement. The result was that local healthcare services, especially in patient’s homes, became the ideal context to solve those problems. Healthcare workers agree that identifying and treating cases early, managing patients with medium to serious conditions- with the consequent reduction of A&E influx- and facilitating the discharge process for patients that were not fully stable were key factors to fight the epidemic. All of this could only be achieved in places where the local healthcare services managed to cover the huge amount of prevention and intervention work required by the situation.
The experience acquired during the first year of the pandemic within this context pointed to four central themes.
1. Flexibility. Responding to the changing healthcare needs of the population, during emergencies as well as other times, requires the quick adaptation of the routes to support and the introduction of innovative interventions. The assessment of the first year of the pandemic and a series of other experiences highlighted that it was only possible to adopt such a flexible approach thanks to the presence of strong management that was in control of local procedures.
2. Integration. The success of operations based on change and the introduction of innovation depended solely on the ability to overcome barriers and to fully integrate the various elements of local healthcare services. That meant creating a single team- composed of GPs, primary care paediatricians, units and departments of primary care, special care continuity services and social services- to join forces and work on shared targets with a complementary and coordinated approach. Furthermore, concrete steps forward were finally taken towards the much-discussed integration of hospital and local healthcare services, even though this largely needs perfecting. Finally, there was a clear need to renew the relationship between the SSN and nursing homes, especially in light of the inadequate responses displayed by these facilities to face an emergency that significantly impacts the vulnerable subjects they are responsible for.
3. Digital technologies and their potential. During the epidemic there were countless technological applications that concerned a great range of contexts and they were often the key element for the successful outcomes of care interventions. The specific indications that emerged around the most important fields of application are the following:
- It seems crucial to have a shared platform whenever part of the support requires online work;
- It is possible to complete the day-to-day triage of large population groups, such as that of people infected with the virus, only through such technologies;
- Physical distancing was achievable mainly through telemedicine and teleconsulting;
- The ability to regularly monitor patients at home was only feasible thanks to IT tools, even simple ones, which were accessible to each patient.
4. The community networks. Formal and informal community networks constitute a resource with great potential for support services but they have not been explored much. Whenever these networks were valued and strengthened they were shown to improve the quality of the healthcare provision and to positively impact the overall health of the population.
Overall, the most successful experiences of local healthcare provision during the first year of the pandemic in our country highlighted three crucial aspects: management, placing the patient’s home at the centre of the service provision and changing organisational models.
The process of changing organisational models is quickly steering towards the formation of networks, the removal of organisational closed loops and the difficult integration between the different levels of care support.
Management is essential to ensure the flexibility of organisational and operational models, the innovation of routes to support and the integration of services that never collaborated together. The structural integration of the newly acquired experiences into the system and into the procedures of healthcare service provision will require great governance efforts.
The pandemic crisis demonstrated that placing the patient’s home at the centre of the service provision ensures compliance with physical distancing; however, it can also bring results in terms of humanising care support services and improving the cost-efficacy relationship.
The process of changing organisational models is quickly steering towards the formation of networks, the removal of organisational closed loops and the difficult integration between the different levels of care support. In order to deal with the changes- that, thanks to the pandemic, were found to be necessary and indispensible- to the provision of local healthcare services firstly we need to understand that changing procedures takes priority over enhancing services.
During the pandemic the Italian Federation of Local Healthcare Agencies and Hospitals collected information and discussed, on webinars and other platforms, numerous experiences acquired by local healthcare agencies, so that other services could learn about them and replicate them. Many of them are quite significant. The following summary sheets describe five such experiences.
The Covid station for home-based healthcare
From the first phase of the emergency to the consolidated management of Covid patients through local healthcare services
The primary care sector was involved in the management of the Covid emergency too early. During this year we established various working procedures and practices that impacted profoundly on the functional aspect of home-based health care.
The positive organisational experiences that we acquired during the first period, March-September 2020, were enhanced and integrated into the system in the following period.
Initially the Covid station for primary care, composed of GPs and head nurses, managed the dispatch of healthcare resources, prioritising the management of patients and anyone they lived with. It covered a range of services, from providing diagnoses to contact tracing and the management of home-based health care, guarantying daily monitoring and keeping track of the activities taking place on the @home Cloud platform. The drive-through testing sites were prepared at the end of March. The Covid station created and assigned care plans to the 11 teams of local healthcare workers and managed the discharge of patients from hospitals and A&Es sending them to alternative facilities (Covid hotels) other than the patients’ home.
Between March and June 2020, 11 USCA (Special Units for Continuity of Care) physicians, 20 nurses specialised in home-based care and roughly 80 workers- mostly nurses- covering the phones, provided home-based care to roughly 10,000 citizens, out of which 5,400 had Covid.
Meanwhile there was an unexpected increase in the provision of regular home-based palliative care.
In September 2020 the public hygiene service was moved under the Department of Prevention together with the public health and contact tracing functions, while the management of patients that were not hospitalised and the drive through services remained the responsibility of the primary care sector.
According to the model governing Covid patients’ care USCA doctors are still required to become part of the organisational context of home-based care, thus creating an important bridge for the network of support services, a trait d’union (a link) between the patient, the GP and the hospital. The insertion of young colleagues in a solid and supportive multidisciplinary context turned out to be very effective in terms of promoting constructive relationships between services and the different levels of care delivery.
The progress of the @home platform, which has been in use since 2018, enabled the continuity of information sharing between all the professionals involved.
Simona Sforzin, Renata Brolis, Giulia Crema Falceri, Oliviana Gelasio, Paola Leonardelli, Stefano Toccoli
Healthcare Authority of the Trento province
Telemedicine and telerehabilitation in child and adolescent neuropsychiatry
From the use of an emergency tool to the improvement of clinical practice
The Covid-19 emergency made it necessary for child and adolescent neuropsychiatric interventions, including rehabilitative ones, to transform very quickly into telemedicine- the only option to guarantee maximal continuity and support for patients and families with a minimal risk of spreading the virus.
During the 24 February-30 June 2020 period 1,382 users could receive support, compared to 1,688 from the same period in 2019- a total of 15,933 interventions compared to 16,879 from the previous year. Out of these, 374 received rehabilitation support, compared to 379 from the same period in 2019.
Telematic interventions with certain activities and service users resulted in higher efficacy, efficiency and usability compared to the in-person ones. This highlights the need to consolidate the adoption of treatment journeys that integrate in-person activities with telemedicine/telerehabilitation.
To be specific, they allow for:
- A more active and cooperative role for the patient and their families and more attention from the workers around how to complement these aspects;
- The improvement of diagnostic pathways, access to more detailed information from the first contact, a better definition of the priority level and better knowledge of the care journey for service users;
- Greater knowledge of the clients’ specific home space and environment, which is essential to better tailor interventions to their needs;
- The implementation of training sessions for parents, with both group and one-to-one interventions;
- The preparation and availability of significant psychoeducational material- shared among services- to support interventions;
- A simpler way to manage online meetings with schools and other local health authorities, with the option of having more workers participating;
- More frequent but shorter interventions wherever there is low engagement/compliance (due to the client’s age, social context or current mental condition) or where the situation requires closer monitoring and more contact;
- The prompt activation of interventions around the client’s environment, also in situations where direct interventions with children/young adults are not yet feasible.
Reducing the moving time for workers and service users also simplified the identification process of shared spaces- meant as a target anyway- an important element to ensure continuity of access to support services.
Maria Antonella Costantino, Laura Chiappa
Ca’ Granda IRCCS (Institute for Research and Care) Foundation Maggiore Polyclinic Hospital (Ospedale Maggiore Policlinico), Milan
Management of the Covid pandemic in the nursing homes of the Reggio Emilia province
The experience of the health authority of the province of Reggio Emilia
Reggio Emilia has 61 residential care homes (CRAs), hosting a total of 2,790 approved bed spaces. During the first phase of the pandemic 40% of these facilities were impacted by Covid-19. Since the first tragic effects of the epidemic began to emerge a significant amount of measures was put in place throughout the province in order to support all the residential facilities, whether they were privately funded or accredited ones. The Local Provision of Healthcare and Social Services Conference outlined the measures in an intervention plan for the containment of the outbreak that had already been approved in March 2020.
Since the very beginning the facilities were inspected by a task force- composed by workers from the Health Authority and a team of operators from the local support services of the district- which was available 24/7 in order to identify early any challenge and plan improvement actions. A screening program involving everyone- the staff and the guests of all the residential facilities- was put in place to complete swab tests. Personal protective equipment was provided together with training on its correct use. Training was delivered both remotely and in loco, involving tutors with a degree in nursing sciences.
The USL of the Health Authority enhanced the nursing and physician staff teams in order to respond to the challenges derived from the lack of staffing in the CRAs; for example, during the first wave it provided 112 additional nurses.
Education was definitively crucial during this process- whether it was delivered remotely or in person within the facilities- particularly on the frontline.
In addition to these organisational and care interventions, our Health Authority decided to view the CRA as a home to its elderly guests and activated a network of specialised clinicians aimed at keeping the elderly patients inside their own environment, especially in cases where hospitalisation would not bring any benefits.
A Covid CRA- a facility with 20 bed spaces (38 during the first phase of the pandemic) meant for the temporary hospitalisation of elderly patients with Covid- was also activated and made available to the whole province.
Furthermore, we tried to place particular attention on the psychological impact of the situation on the elderly guests and the staff, and provided psychological support. The goal was also to maintain stable interactions with the families so that the elderly guests could stay in contact with their loved ones- through video-calls or alternative modalities that allowed external visitors to resume access in a safe way.
Last but not least, a vaccination plan was implemented throughout all the facilities, reaching, as of today, 97% of the guests and 75% of the staff.
One year on from the start of the pandemic we were able to identify the following key strategies that enabled us to optimally face this difficult time: the strong governance from the general management and the district directorate that could coordinate and integrate all the new interventions into the system; the constant communication with institutions and the ongoing dialogue between executive management and the managing bodies; the prompt analysis and management of new cases; the digitalisation of data collection and its continuous analysis; and the use of training as a push for change.
Managing this emergency has therefore guided us towards the permanent introduction of organisational changes. Examples of these are the constant dialogue with management bodies, valuing the collaboration with reference figures that could manage the crisis inside the nursing homes, planning continuous training, etc.- measures that were all implemented during the ongoing reorganisation process.
USL (Local Healthcare Unit) of the Health Authority – IRCCS (Institute for Research and Care), Reggio Emilia
The continuous service delivery of a non-Covid IRCCS
A safe hospital close to patients
The IRCCS IFO remained a non-Covid hospital during the pandemic. The guiding principles for interventions were: internal safety during treatment delivery and external continuity for those who could not or chose not to access services in person.
The following strategies were implemented in order to ensure internal safety:
- The activation of three triage locations, which enabled the identification of suspected Covid patients, signposting them to Covid hospitals or primary physicians, and the monitoring of patients and staff’s access;
- Swab PC tests for workers and patients, operating procedures and tools to contain the viral spread;
- A location dedicated to the management of logistics- reviewing waiting rooms and internal routes, the daily need of PPE, emphasising distancing requirements and smart working options and, finally, actively monitoring healthcare workers.
In order to ensure the continuity of healthcare provision we planned for “a hospital that would be close to patients”. We activated a drugs home-delivery service and, just in the first phase, 450 patients received their oncological and treatment drugs. New methods of communications for physicians, psychologists, nurses and patients were established. There was a helpline for patients, caregivers and professionals, and a telemedicine platform (#IFOConTeOnline, which translates to “#IFOWithYouOnline”)- utilised by more than 2,000 patients- to check symptoms during follow-up or intermediate periods between treatments, to advice patients and their caregivers, and to enable the delivery of medical, diagnostic imaging and healthcare reports. Finally, there was also a helpline to promote good mental health among patients. The care team was therefore enabled to maintain the therapeutic relationship with patients without interruptions, while patients could keep in contact with the team and their treating professionals, despite any mobility restriction or personal barriers.
The IRCCS IFO introduced new measures of internal and external communications to effectively raise awareness on health risks and the required preventive behaviours that patients and their families should adopt to avoid them. The general manager’s weekly “open letter” addressed to workers, instead, helped to explain the reasoning behind the operational procedures and to support their application during the toughest phases of the epidemic.
The key to the success of phases 1 and 2 was to ensure, even through the use of unusual means, the continuity of support and healthcare services without ever disconnecting the delivery of good quality care from the protection of public health. In phase 3, which took place during the second wave, the previous measures were adopted again.
IRCCS (Institute for Research and Care) IFO (Physiotherapy Hospital), Rome
The Accasa (“At-home”) service: telemonitoring and telesupport for Covid patients
For the care of covid patients
The service described is an adaptation, designed for Covid patients- with fewer functions (a sort of lighter version)- of the larger TALIsMan project, which started in September 2018 and is still ongoing. The main goals of the original project were the search and proposal of integrated care models that could provide support services to vulnerable patients in their home, with the help of IT tools.
The Covid-19 emergency, and the forced quarantine periods that came along with it, highlighted the need for solutions that, similarly to the TALIsMAN pilot project, could activate telemonitoring, televisiting, teleconsulting and remote support services in general, in order to enable the continuity of service provision. The changes to the TALIsMan project adaptation, which was meant to support patients during the crisis, involved IT tools that could monitor clinical parameters, lifestyles, adherence to treatments and the social support needs of the service users remotely, and share these on a single platform with all the professionals involved in the patient’s care.
This service solution entails an IT platform based on a two-pillar approach: the multidisciplinary support team- composed by various professionals and with a flexible profile- and the shared care plan, which is tailored to the patient’s needs.
Patients or caregivers can access the platform to request services through a mobile-friendly web app (accessible from mobile, smartphone and tablet). The app is available in two formats, each with different diagnostic tools: a simpler one, with the oxygen saturation meter, and a more advanced one, with a Bluetooth tablet, a hemodynamic monitor measuring multiple parameters, a cardiographic device, a glucose meter, a body composition scale and a sphygmomanometer.
The measurements are displayed under the patient synopsis form, which highlights the expected timeline and the relative documents. This can be shared between professionals during one-one or group video consulting.
The Accasa (At-home) lighter service solution, designed for generic Covid patients, was also particularly welcomed by oncology patients and those suffering with rare conditions as it enabled them to re-establish contact with their network of support services.
The Accasa (At-home) service had another unforeseen and interesting application in nursing homes (20 as of today). In times of peace the systemic monitoring enabled by the service, especially through the use of the advanced diagnostic tools, could have- maybe- resulted in quicker interventions to isolate the outbreaks.
Giovanni Gorgoni, Francesco Fera, Giovambattista Gaudino
AReSS (Regional Strategic Agency of Healthcare and Social Services), Puglia