Giorgi Gianni
Istituti Clinici Scientifici Maugeri SPA, SB.
G Ital Med Lav Ergon. 2018 Feb;40(1):6-21.
The increase in the average life expectancy entails elderly and chronic patients as hospital users, often dependents and requiring recurrent hospitalizations. In this framework, an innovative model of care management is essential to ensure appropriateness and sustainability of health services.
A highly specialized care-related prevention-treatment-rehabilitation approach in which pharmacological, surgical, physical and intellectual disability therapies coexist in a synergistic manner, is the answer to this new emerging need. It offers interdisciplinary care pathways facing both disease and disability recognized by severity through ICD and ICF.
Measuring functional status related quality of life is a main outcome to be primarily pursued for complicated chronic patients.
The implementation of "need-adapted" pathways agreed within multidisciplinary teams is the key feature of this new clinical model that can take advantage of data mining tools combining medical know-how and diagnostic information.
平均预期寿命的增加使得老年患者和慢性病患者成为医院的使用者，他们往往需要他人照料且需要反复住院。在此背景下，创新的护理管理模式对于确保卫生服务的适宜性和可持续性至关重要。
一种高度专业化的与护理相关的预防 - 治疗 - 康复方法，其中药物治疗、手术治疗、物理治疗和智力残疾治疗以协同方式共存，是应对这一新出现需求的答案。它提供了通过国际疾病分类（ICD）和国际功能、残疾和健康分类（ICF）按严重程度识别疾病和残疾的跨学科护理途径。
对于复杂的慢性病患者，测量与功能状态相关的生活质量是主要追求的主要结果。
在多学科团队内商定实施“按需调整”的途径是这种新临床模式的关键特征，该模式可以利用结合医学专业知识和诊断信息的数据挖掘工具。
