Covid-19: Lessons learned from Phase 0
The spread of the epidemic from Covid-19 is highlighting, with unprecedented strength, not only the degree of preparation of our Healthcare System, but also the contradictions that it had well before the proliferation of infections. In more than one passage, the leaders of the Civil Protection have underlined the extraordinary nature of the emergency that involved the public car complex and which has no comparison with other exogenous shocks. However, as has occurred in recent times with post-seismic emergencies, Such disruptive phenomena have highlighted the pre-existing deficiencies in our ability to face them.
In the current state of things, it is not possible to make a complete assessment of the different reaction capacities of public systems to Coronavirus, if only because the medical-scientific community itself is also looking for reliable drivers of the epidemic. Reconstructing the puzzle of what this collective stress test has highlighted, on the other hand, seems right to imagine new organizational trajectories of the different health and care levels put in place.
While the emergency situation confirmed the quality of our health system, based on universality and quality of care, on the other it exposed the fragility of a system still based on the hospital, demonstrating its centrality with respect to the “system territorial health“. This certainly happened because the territorial assistance has less sedimented procedures than the hospital one and, therefore, in emergency we have relied on the more “run-in” machine, but also because in many cases the territory has not shown itself sufficiently ” equipped “for the management of patients who are less serious or not yet in the acute phase.
Yet, in Italy, as early as the second half of the twentieth century, the hospital-centric vision was questioned in favor of an approach of the care system to the territory; although it will be necessary to wait for the reorganization decrees of 1992 (Amato, De Lorenzo – DLGS n. 502) and 1999 (Bindi – DLGS n. 229) for this trend to find an explicit response. These reforms, in fact, have given impetus to a shift of the axis of governance through the transformation of the USL into real companies, also on the basis of the push to resume the centrality of the organizational and technical-scientific aspects in health. However, the traditional acute-care hospital and the particularly fragmented territorial system continued to reveal a management inadequacy, with evident repercussions on the offer of care that appeared dichotomous and poorly integrated in terms of levels of care. Only in 2012 the Balduzzi law (n.189) intervened which, together with the Health Pact 2014-2016, rearranged the primary care system and, promoting integration with the social and hospital services, entrusted the Regions with the task to reorganize the territorial services according to new organizational forms and operating methods (creation of territorial functional aggregations -AFT- and complex units of primary care -UCCP-, which aim at the “network” provision of care services). At the same time, the districts, the “front” of integration and guarantors of the balance between the care chains, have evolved according to national guidelines and regional strategic guidelines; the Regions have dedicated investments to the organization of care and intermediate structures for de-hospitalized patients who need health support in protected areas; we witnessed the emergence of multiple new multifunctional structures (for example, Case della Salute) for continuity of care and the satisfaction of socio-health needs. From 2012 to today the processes of change and experimentation have never stopped and several regional Health Services (including those of Veneto, Lombardy and Emilia Romagna) have issued ambitious social and health reforms and plans, which have led to models of assistance territorial diversified.
Describing them in detail in their operating and delivery procedures, as well as providing a quantitative and homogeneous assessment of the real degree of integration between hospital and territory within individual contexts, remains a complex operation.
What is immediate to infer from reading the available data is that, in pre-Covid Italy, the accessibility and functionality of the territorial health services were extremely differentiated between regions.
The “Report on the hospitalization activity SDO 2018” of the Ministry of Health highlights very different results regarding the use of hospitals for selected diseases that can be treated at a territorial level, as well as the last Statistical Yearbook of the National Health Service underlines a high variability regional in relation to all the pillars of district assistance (number of general practitioners, paediatricians and medical guards per 100,000 inhabitants, cases treated in integrated home care per 100,000 inhabitants, provision of clinics and laboratories, etc.). This heterogeneity is confirmed by the analysis of the indicators relating to district assistance considered in the last LEA Grid (verification of the delivery of the Essential Levels of Assistance).
Lessons (not) learned
In 2017, Nomisma concluded an article on the degree of hospital-territory balance: “The level of guard on strategic reorientation towards territorial health must remain high. The data show that the redefinition of care models is bearing fruit; at the same time the steps to be taken remain many. It is true that the hospital-territory relationship cannot be assessed as a mere transfer of benefits from one to the other, nor measured solely in terms of savings achieved. However, it is equally true that, in an uncertain and changing context such as the current one, it is crucial to provide evaluation and control tools capable of detecting successes and critical issues and suggesting corrections“.
We would all have hoped that the opportunity to do this would not arise following the outbreak of an epidemic of this seriousness; however, the test to which our National Health Service is still subjected, makes clear the urgency of making concrete progress in this direction, asking questions which in the light of the emergency seem almost rhetorical: hospital care should have been more assisted by the territorial one in the management of the emergency? If the territorial centers and intermediate structures had been more “equipped” (also in terms of digitization of services), could the regions have better managed the positive non-hospitalized patients? Could more effective monitoring have been carried out?
Speeding up awareness of what the Coronavirus shock has brought to light therefore becomes a priority, as well as untie the knots of the hospital-territory integration process. Of these, two are worth mentioning briefly.
Crossing the border between health and welfare
When proposing a strategic reorientation towards territorial health, a fundamental redefinition of the entire model of health services that intersect with care services must be taken into account. In a profoundly changed society, where family and social relationships are dilated, where aging and loneliness characterize internal and urban areas and the health system must make up for a retreat in the social status (subject to decennial cuts in transfers to entities Premises), the integration process between health and welfare needs to be accelerated.
Health is the result of the “relationships” between systems in which the person is inserted (family, environment, training and school, work, justice, …); among these, “health” and “social” are those for which integration is essential for strong interconnections and it cannot have a single reference model: different degrees of admixture are needed, but connection and coordination is needed, participated and shared, that is, “governance” both at regional and local level.
The prospect of a new, necessary, “socio-sanitary paradigm” passes for the construction, jointly, between health workers (ASL and AO) and social workers (single and associated municipalities) of Integrated Health and Social Care Paths able to: give increasingly appropriate and integrated answers to citizens’ health needs; determine the shift of the center of gravity from the hospital to the territory; develop integrated management logics of the offer of extra-hospital, social-health and social services; guarantee continuity of care in care pathways intended as an integrated path between the networks of health services (hospital and local) and social services. These processes will lead to overcoming the contrast or juxtaposition between “health systems” and “social systems”, for the realization of “health systems” (Cit. Nomisma, Health and Social Systems in Europe and in Italy: Problems, Opportunities and Trends, Bologna 2016).
Among other things, the presence on the national territory of Foundations, associations with welfare, recreational, sporting and cultural purposes represents a contribution of different resources in the care of the person, as well as informal resources such as neighborhood networks, solidarity condominiums and other forms of solidarity intervention.
It is an enormous national heritage which, with a view to an integrated health and social system, would constitute a unique strategic asset on the world scene.
Intervene on “hardware” and “software”
Always excluding evaluations on the most useful technical applications during the epidemic phase, ithe consolidation of the “hardware” of the territorial services must necessarily pass from a parallel strengthening of the “software” in the hospital and home environment.
Indeed, it is necessary that the technology bridges the two levels of care and that the information flows are usable regardless of the context in which the patient receives care. The enormous clinical, diagnostic and therapeutic information heritage is, to date, largely dilapidated: one of the most striking examples concerns hospital medical records which, “traveling” still on paper, mean that, in the vast majority of the cases, the information collected in the patient monitoring phase is dissolved simultaneously with the patient’s discharge.
The way to go is even longer when we talk about new technologies to support home care. Undoubtedly the Coronavirus is accelerating the use of apps, borrowed from experiments in the treatment of chronic diseases, which allow to monitor the parameters of patients remotely, creating a valuable experience that will surely be useful even when the epidemic has disappeared. However, if in the past the guidelines relating to the use of telemedicine had been more implemented, we could probably have reduced the impact of the virus for some cases and certainly could have had a greater continuity in the relationship between doctor and patient, with obvious advantages also from a social and psychological point of view. The use of telemedicine, however, still appears to be marginal both due to the cultural reluctance of potential patients and because of the digital divide between generations and between territories. Computer literacy for the population groups less accustomed to the “new” tools and intangible infrastructure therefore appears to be the necessary prerequisite for increasing trust and acceptance towards these types of tools.
* Nomisma researchers