New tools for the integrated management of care pathways for chronic patients In the management of chronic patients, the traditional framework characterized by opposed care settings (hospital-primary care) struggles to guarantee quality of care, customized assistance and overall financial sustainability. Local health authorities aim to promote networking among health professionals to improve value for patients, but they still base their planning and control systems on single care setting, hospital versus primary care. The aim of this study, carried out in the Italian context (Tuscany), is to experiment a methodology to identify referral networks of professionals treating chronic patients (in this case with heart failure) and to measure their outcomes and clinical appropriateness. Performance evaluation of the care network can be an effective tool to improve care while creating an accountability system consistent with the new organizational models.
Keywords: Chronic care, heart failure management, clinical pathways, performance evaluation, care networks, referral