It is widely acknowledged that reorganising the healthcare system requires the reform of the network of local support services. The Covid-19 pandemic highlighted this aspect even more, especially during the first acute phase: wherever the network of local services corresponded to consolidated and coordinated service delivery in reality- and not just on paper- the response was more efficient.
The Ministerial Decree (DM) n.70 of 2015 reorganised the hospital network and this measure- wherever it was applied- turned out to be essential to be able to sustain the impact on A&E departments and hospitals. Such level of emphasis was not placed on a concomitant reorganisation of the network of local support services, even though there would have been enough regulatory and reference elements to do so. This aspect and its sporadic and incomplete application were the only defects of the DM n.70.
The first steps during the crisis
The Law n.34 of 19 May 2020 outlined different urgent measures for the healthcare sector: article 1 concerned the reorganisation and enhancement of the delivery of local support services and article 2 focused on the enhancement and improvement of the hospital network. Thanks to the latter the reorganisation of the ICU beds management could take place and the concept of semi-intensive areas was introduced.
Article 1 outlined two structural elements that are important for reforming the way local support services are delivered and coordinated. The first one was the introduction of 9,600 family or community nurses, which ensured continuity of support and that the maximum amount of patients could be supported. The second one was the activation of coordinating stations that connected the local support services of the area with emergency services and hospitals, finally facilitating communication between all the parties involved in social healthcare. In practice it is these coordinating stations that made the difference for the management of the Covid-19 emergency in regions such as Veneto, Lazio and Emilia-Romagna. These regions utilised already existing stations or created new ones locally, inside local health units (LHAs) and regionally, and worked on making the use of monitoring systems more efficient, starting with telemedicine. This way they were really quick in creating a coordination system for all the different prevention and home based support services as well as those monitoring Covid-19 patients, which was the remit of the special units for continuity of care.
Therefore all these elements- that already sort of represent the basic grounds of DM n.34- and the extraordinary push towards a multidisciplinary cooperation between several professionals, which was triggered by the Covid-19 context, were leading factors for the definition of both the National Recovery and Resilience Plan (PNRR)- the healthcare part of which was coordinated by the manager of the Technical Secretariat of the Ministry of Health- and the definition of the basic provision of local support services. These would be outlined in the so-called DM n.71 (named this way because since the publication of the DM n.70 those of us working in the field always felt the need for a twin version of it to be dedicated to the network of local support services).
The workgroup of the Ministry of Health, coordinated by the General Manager of the National Agency for Regional Healthcare Services (AGENAS) that played an essential role for the creation of the PNRR also by providing fundamental know-hows from the good practices of the regions, is currently making a document on the reorganisation and definition of the standards for local support services.
Network for widespread support provision
The PNRR sets out the creation and implementation- with the help of European funds- of an extensive network of widespread local support services comprising of 1,288 community hubs, 375 community hospitals and the increase of the existing bed spaces from 1,200 to 7,500 as well as 602 local coordinating stations. The community hubs host general physicians, freely chosen paediatricians, nurses, social assistants and other professionals in the same multidisciplinary facility and put them in contact- in person or online- with all the different specialists and relevant services via the coordinating stations. According to the plan there should be a community hub available every 20-25,000 inhabitants and this should also be connected to any marginal local support services present in disadvantaged and mountain areas, in line with the hub & spoke model.
The remit of community hospitals is somewhere between home based assistance and hospital based support. They are meant for short-term hospitalisations that require low maintenance care and nurses predominantly manage the healthcare. In addition to lightening the burden on the hospital network they also constitute an element of continuity of care between hospitals and local support services in that they guarantee a greater degree of home based care and help with chronic cases that become more acute or that would be more difficult to manage just through home based care.
The goal is to ensure continuity, accessibility and integration of the support.
The value of coordinating stations
Coordinating stations are the organisational pillars that the network of local support services and its interconnection with the other networks is founded on. Their function is to coordinate and connect the different services and parties involved in the network of support services, ranging from community hubs to community hospitals, home based support and prevention services, mental health support services, sexual health clinics and veterinary services. The goal is to ensure continuity, accessibility and integration of the support through a service that is mainly dedicated to the healthcare and socio-healthcare workers of the area, which it depends on.
According to the PNRR there should be 602 coordinating stations, one every 100,000 inhabitants. This will have to take place in line with an organisational model that also takes into consideration the dispositions of the 2016 State-Regions Agreement as well as the European commitment to activate a European helpline- 116117- for non-urgent medical care.
The “116117” regional coordination hub is a reference point with a capacity ranging from 1 to 2 million inhabitants- it is meant as a regional service- and it provides users with information on the local support services available in the area and how to access them. The plan is for it to be in contact with the relevant coordinating hubs of the area, the hospital network and most importantly with the network of emergency support services so that cases the need these types of services can access the right route to support. Its remit does not clash with that of local coordinating hubs but rather it strengthens the coordination process in order to provide a prompt and reliable response to the users’ need for information.
The greatest challenge will be to ensure that the healthcare and social sectors can collaborate with each other, especially to reach the most disadvantaged groups living in big cities.
Collaboration between healthcare and social sectors
It is becoming more and more evident that managing healthcare and socio-healthcare needs requires a holistic approach, one that is closer to families and to the community, that utilises modern and easy to use technologies, information that is widely available and accessible to operators, and even highly advanced tools such as artificial intelligence. It is therefore necessary to pull down divisions and barriers- even cultural ones- get past systems such as the PDTAs (routes to get diagnoses and support), which were useful to manage pathologies rather than people, and introduce stratification and management tools. For example, this could be achieved by improving and developing personalised support plans that aim for a holistic approach to support based on the degree of complexity, viewing the healthcare system as a group of coordinated services that communicate with each other.
Thanks to a well-organised network of widespread local support services offering the adequate healthcare workers available and the help of telemedicine and advanced technology it will be possible to reach even the most remote parts of each area. Mountain areas will not constitute an obstacle or a limit to the provision of healthcare services anywhere.
We have several instruments available. However, what matters most is what support services are present in the area and their ability to manage individual or community needs, including those of hard-to-reach groups and population groups that are hidden, usually because of their social or economic conditions. Absurdly it is easier to intercept a 90-year old that lives alone in a small mountain community than to treat someone hard to reach and hard to identify that lives in a big city such as Rome, Milan or Turin who then shows up at the emergency room due to needing acute care with no history record.
Therefore the greatest challenge lies in creating a collaboration between the healthcare and the social sectors, especially to reach socially disadvantaged groups living in big cities, that often experience precarious living conditions in densely populated areas and, despite being more prone to get sick, struggle to access healthcare and other essential services.
In the past we saw some regions and local healthcare units show a strong desire to create a network of support services. Covid-19 created the ideal conditions for a reform. As Giovanbattista Vico put it, “They appeared like obstacles but they were actually opportunities”. Covid-19 forced us to communicate and find a sense of solidarity. It enabled us to collaborate on shared projects and be active on the frontline. For example, the coordinating station based in Rome managed the launch of a helpline service (free line 800.118.800) that provides information and support by proactively reaching out to home based patients in order to monitor their health status or to remind them about a diagnostic exam. This is a model of how management of the needs of the individual is achieved through home care and the community. Covid-19 also forced us to trial the use of telemedicine to respond to the needs of patients and to manage the pandemic emergency.
Overall Covid-19 accelerated the reorganisation of networks of local support services, not just on a regulatory level but also in practical terms through the activation of organisational models and the use of ICT (Information and Communication Technology). What might make a difference today compared to the past is indeed IT and telematic coordination in combination with the routes to support chronic issues and good practice, which are at the heart of the European project that was given to the Ministry of Health: the PonGov (National Governance Operative Program) Cronicità (on Chronic Issues) project- facing the challenge of chronic issues with the help of ICT- managed and coordinated by the AGENAS.
The urgent need to improve the provision of local support in order to face the pandemic accelerated a process that people already felt the need for. Articles 1 and 2 of Law n.34, which I had the honour to contribute to, were the foundations of this process that, like a magnet, brought all the parties of the system together to meet with each other and to seek a common ground to reach an agreement between the State and the Regions that could define the reorganisation of the provision of local support. This entailed looking at what was already outlined in pre-pandemic policies, starting from the State-Regions Agreement of 7 February 2013, with the guidelines on the reorganisation of the emergency services system- focused on continuity of service provision- the establishment of coordinating stations that used shared IT platforms, the State-Regions Agreement of 24 November 2016 and the activation of the European helpline (116117) number.
AGENAS plays an important role in this journey dedicated to building a network of local support services as it coordinates the team that will create the document to be presented to the workgroup of the Ministry of Health and to the State-Regions conference. The PonGov Cronicità project is its facilitating substrate that aims to create a true community of professionals and institutional parties by sharing great experiences and best practice between the Regions, the LHAs, the boroughs and all the operating parties.