A proactive and multidisciplinary approach to community-based care for frailty: The experience of the Forlì District of the Romagna Local Health Authority (AUSL Romagna)

Journal title MECOSAN
Author/s Davide Botturi, Stefano Boni, Laura Tebaldi, Giuliana Valli, Cristiano Artusi, Giuseppe Benati
Publishing Year 2025 Issue 2024/130
Language Italian Pages 12 P. 7-18 File size 0 KB
DOI 10.3280/mesa2024-130oa18955
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During the period 2016-2019 in Forlimpopoli Community Health Centre, Forlì Health District (Local Health Unit of Romagna), was implemented a methodology aimed at proactive and multidisciplinary care of frail community dwelling adults, named RiskER. It consists of: individual high frailty risk profile analysis by General Practitioner (GP) and nurse (the profile has been processed by validated algorithm); needs assessment of persons eligibile for interventions by GP and nurse, with social worker involvement, on the basis of disposable information, and identification of potential interventions; intervention proposal to the person by nurse. The main interventions are: enrollment in care pathways for chronic diseases (type II diabetes, heart failure, COPD); improvement of therapeutic compliance; nursing and/or social home care.

Keywords: Frailty; Identification and management; Community Health Centre

Davide Botturi, Stefano Boni, Laura Tebaldi, Giuliana Valli, Cristiano Artusi, Giuseppe Benati, Un approccio proattivo e multidisciplinare per la presa in carico territoriale della fragilità l’esperienza del Distretto di Forlì dell’AUSL della Romagna in "MECOSAN" 130/2024, pp 7-18, DOI: 10.3280/mesa2024-130oa18955