NEWS FROM THE REGIONS
Individual pathways of care: a new model of care in Lombardy from a gender perspective
Franca Di Nuovo1, Ida Maria Ada Ramponi2, Giulio Gallera3
1Lombardy Region Gender Medicine Contact Person; 2Director General Asst Rhodense, Garbagnate Milanese, Milan; 3Lombardy Region Welfare Councilor
On the Italian scene, the Lombardy Region has always stood out for having created a health system of excellence, capable of providing health services that meet the health needs of its citizens. The new needs for care and assistance, also affected by the socio-demographic changes under way, have led to a rethinking and a substantial change in Lombardy’s health policies, resulting in Regional Law no. 23 of August 2015 “Evolution of the Lombardy health and social system.”
In order to implement an innovative and proactive health system, which is able to place the emphasis on the concept of organizational appropriateness of care, the reorganization of the Lombardy health and social system has begun, also to meet the changing needs of a population that in the next decade will be made up of about 25% of elderly people over the age of 70. This is a substantial cultural change, which is also changing the Lombardy health organization with the aim of ensuring the principles of universality, equality, respect for individuals and their freedom of choice of healthcare guaranteed by the Italian National Health Service.
This model, approved with the Resolution “Reorganization of the supply network and methods of taking charge of chronic or frail patients,” places the patient at the center of the system and is based on the Individual Care Plan (ICP) and on taking charge of elderly patients mainly affected by chronic diseases. The aim is to improve the quality of life of Lombardy’s citizens while guaranteeing greater appropriateness and adherence in taking care of patients suffering from chronic polypathology. From this point of view, the concept of personalized care, the constituent and founding criterion of the ICP, becomes the link to gender-specific medicine, a cross-cutting branch of medicine that studies the influence not only of sex (and therefore of the biological differences between men and women), but also of ‘gender’ (and therefore of the environmental, social, cultural, demographic and relational factors that characterize each individual) on the state of health of every one of us.
Talking about gender in medicine therefore means talking about a culturally dynamic concept, which must inevitably reflect the social and demographic changes unfolding in society, whose influence also manifests itself on the state of health of people to the point that health is a phenomenon built, interpreted and lived socially, where gender plays a fundamental role, being one of the determinants of health that can transform biological differences into social differences.
For this reason, gender-specific medicine enhances and strengthens the concept of personalized care and assistance, with the aim of ensuring to all that health care treatments are delivered as best as possible in the fields of prevention, diagnosis, therapy and rehabilitation.
From this point of view, the ICP can be understood as a model of gender-oriented care, since it meets the criteria of appropriateness and customization typical of gender-specific medicine. Without a gender approach, health policies are methodologically incorrect, biased and inappropriate. Therefore, the ICP aims to implement a pathway to protect health that pays attention not only to the biological factors of a disease, but also to the determinants of health starting from the sociological, ethnic and cultural scenarios that distinguish each individual. In the awareness that gender health is an essential element and that a change in the strategy of healthcare policies has now become inevitable, the Lombardy Region was one of the first regions to include gender medicine in the regulatory documents of the Regional Health Service.
The Regional Development Plan of the 10th Legislature (2013-2018) introduced the concept of “gender perspective” to implement new promising projects in both hospital settings and locally. The resolution on “System Rules” no. X/1185 of 20 December 2013 dedicated an entire section to gender medicine among the decisions regarding the management of the regional health and social service. The attention has been focused on innovation and organizational planning, which are well combined with the improvement of gender-oriented clinical appropriateness.
Following this leitmotiv, Regional Law no. 23 of August 2015 set out the criteria for developing, in the Lombardy Health Service, new models of care and assistance capable of also responding to the tenets of gender-specific medicine. The reorganization of the health system was based on the awareness that the increasing number of elderly people suffering from chronic diseases calls for a change in the way, timing and processes of delivering health services, adapting them to new care needs. A new model of health services is now part of the changed organizational structure, designed to address the crucial issue of chronicity and frailty in elderly people. The cross-cutting nature of gender medicine promotes the health not only of men and women, but takes into account all the evolutionary ages of an individual, from childhood to elderly age. Therefore, the ICP, dealing with elderly patients at a time when they represent an emerging social reality, meets the tenets of gender-specific medicine. The new model of care that the Lombardy Region has set up to ensure that people in chronic conditions receive better care that meets their individual health needs simplifies the management of chronic diseases for patients, both from the point of view of gender and the economic sustainability of the system. Citizens with chronic diseases were invited by letter to join the new opportunity by the territorially competent Agency for the Protection of Health. After accepting the invitation, citizens could choose the manager to take care of their health needs and who signed an annual “Care Pact” with them. Then, based on the specific clinical needs, a personalized ICP was drawn up for each citizen, including all the necessary prescriptions for the management of the chronic diseases affecting them. The care pact is a real contract, not tacitly renewable, which commits both parties: the manager for the activities and services provided in the ICP and the patient for adherence to the prescribed therapy. In drafting the ICP, the manager identifies a clinical manager tasked with drawing up an individual care plan designed on the real health needs of the individual patient, personalized and appropriate to the complexity and multiplicity of his or her clinical picture. From that moment on, the manager accompanies the patient through the treatment process, planning visits, tests and other treatment needs, supporting him or her in the implementation of the entire individual plan of care. The managing physician ensures the coordination and integration between the different levels of care and the various actors of the Lombardy health and social care service (general practitioners/free-choice pediatricians, specialist physicians, public and private health and social care facilities, pharmacies, nurses, etc.). In the organization of visits and tests, the manager has an articulated chain of facilities suitable to provide the services indicated in the care pathway: therefore, each patient no longer has to worry about booking medical exams and long waiting lists. The ICP could become a tool capable of eliminating gender discrimination and biased access mechanisms to care and services, which most frequently penalize women who often flee care because of the lack of time, and of fulfilling the tasks of caregivers. As documented by health and sociological literature, women – though living longer than men – have a different healthy life expectancy, mainly due to social, cultural, and economic factors. Women over 65 often live alone and have a lower cultural and economic status than men, and these gender-related health determinants can limit their access to care. Lombardy’s ICP is the first version of an instrument of organizational appropriateness that the Lombardy Region wants to implement to leave behind health policies based on obsolete planning methodologies, which do not consider the demographic, social and psychological changes of society. Knowledge of the demographic stratification of the population by age and gender must be the starting point to respond effectively to the demands for health and care, which are different in the various stages in the lives of sick people. The results and performance of the application of this new organizational model, of the taking charge of a patient affected by polypathology, in terms of outcome, must include the determination of the effectiveness and efficiency of the new care process. The ICP, in its transformational vision, is therefore Lombardy’s health challenge of the future, whose effects and expected positive results will mainly consist in the personalization and provision of health services that respect the health needs of the individual. The organizational quality of the new Lombardy healthcare system, by promoting the appropriateness of healthcare programs, will reduce waste and ensure the economic sustainability of healthcare spending, in line with the social context of reference and therefore also with gender differences.
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