Due to epidemiological and social changes related to the increase in the average life expectancy, health users are characterized by elderly chronic and comorbid patients who require recurrent hospitalizations often with disability outcomes. In this framework, an innovative health clinical and management model is the adequate answer to systematically promote the patient independence. The experience on the application of this model is here presented. Main features are interdisciplinary and integrated care pathways facing both disease and disability biologically and functionally diagnosed by ICD and ICF. The definition, personalization of pathways/protocols and outcome evaluation represent the foundations of this new proposed model for patient care. The digitalization of hospital clinical data and medical knowledge make the model feasible.
Keywords: Care-related model, Data mining, Outcome, Dependence, Complicated chronic patients, Digitalized clinical care pathways