The article presents an organizational analysis on a disease management model of care called Integrated Model for Chronic Endocrinopathologies. The hypothesis of the study is that endocrinological pathologies, given their chronical dynamic and their low-mid complexity can be addressed at best by an efficient integration between general practictioner, nurse, endocrinologist and patient. The methodology is based on indicators related to three areas: the community-based health services, the activites of the clinical équipe and the clinical outcomes. The results show that organizational flexibility and technological solutions support clinical continuity of care under three dimensions: stimulus to self-help, prevention and critical events avoidance.
Keywords: Malattie croniche; cure innovative malattie croniche; cure intermedie; integrazione socio-sanitaria; sanità digitale; coproduzione.