Giusti Martina, De Remigis Santa, Greco Stefano, Profeta Valerio Filippo, Bonaccorsi Guglielmo, Zanobini Patrizio, Del Riccio Marco, Lorini Chiara, Di Giosia Maurizio, Persiani Niccolò
Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
Centro Studi SAPIS Foundation, Italian National Federation of Orders of Radiographers and Technical, Rehabilitation, and Prevention Health Professions Research Centre, Rome, Italy.
Front Public Health. 2025 May 21;13:1562564. doi: 10.3389/fpubh.2025.1562564. eCollection 2025.
Globally the ongoing reforms of the national healthcare systems are carrying out social and health services closer to users, increasingly reaching them at home. This approach addresses the challenges posed by population aging, chronic diseases, and social inequalities. Effective solutions require combining experience, expertise, and resources within a unified organizational model for the social and health care services provision. This is particularly crucial for providing integrated care to frail individuals aged 65 or over. This article aims to explore service innovations for frail population aged 65 years or older, focusing on the integrated management of economic and professional resources in health and social services to ensure continuity of care.
The Agency of Integration for Continuity between Hospital and Territory (AgICOT), a service financed by the Italian Ministry of Health designed for frail individuals aged 65 or over in Local Health Authority of Teramo (Abruzzo, Italy) was selected as case study.
AgICOT utilized health plans and health budgets to integrate social and health goals and resources into a single social and health care pathway, avoiding duplication of interventions, saving resources, and ensuring economic sustainability of social and healthcare systems.
AgICOT has demonstrated its effectiveness as organizational response to the complex needs of frail individuals aged 65 or over, ensuring high-quality social and healthcare services in a sustainable manner.
The co-responsibility of various stakeholders has been the key to the success of this project, creating the conditions for transitioning from hospital-based to person-based social and healthcare in line with international recommendations on integrated care and continuity of care.
在全球范围内，正在进行的国家医疗体系改革正在使社会和卫生服务更贴近用户，越来越多地在用户家中为其提供服务。这种方法应对了人口老龄化、慢性病和社会不平等带来的挑战。有效的解决方案需要在提供社会和医疗服务的统一组织模式内整合经验、专业知识和资源。这对于为65岁及以上的体弱老年人提供综合护理尤为关键。本文旨在探索针对65岁及以上体弱人群的服务创新，重点关注卫生和社会服务中经济和专业资源的综合管理，以确保护理的连续性。
选择医院与地区连续性整合机构（AgICOT）作为案例研究，该机构是一项由意大利卫生部资助的服务，面向意大利阿布鲁佐大区泰拉莫地方卫生当局中65岁及以上的体弱人群。
AgICOT利用健康计划和健康预算，将社会和卫生目标及资源整合到单一的社会和卫生保健路径中，避免干预措施的重复，节省资源，并确保社会和医疗系统的经济可持续性。
AgICOT已证明其作为对65岁及以上体弱人群复杂需求的组织应对措施的有效性，以可持续的方式确保了高质量的社会和医疗服务。
各利益相关者的共同责任是该项目成功的关键，为按照综合护理和护理连续性的国际建议从以医院为基础的社会和医疗向以人为本的社会和医疗转变创造了条件。
