[Integrated and structured clinical networks. A new model of pro-active management of chronicity and sustainability].

The population ageing and the increase of the prevalence of chronicity and multimorbidity, require a multi-dimensional and long-term care system, overcaming the current vision "hospital-centered" toword a structured model, able to network services. The new organisational systemic model, named "Integrated and Structured Clinical Network", developed by a experimentation conducted in an Local Health Unit, in Tuscany, has highlighted very relevant results both for the health of the citizens taken in care, redusing the need for hospitalization, the demand for heavy diagnostics (and waiting times ), the access to the Emergency Room and the final costs of care pathways, largely the result of avoidable hospitalization! The project has been developed with the purpose of create a proactive medicine model to managing chronicity, complexity and fragility, in accordance with aims of "Population health management" and with Chronicity National Plan. The organizzational requirements of this new chronicity management model are rappresented by: - Estabilishment of multi-professional team - Multi-dimensional evaluation of clinical and social assistance needs - For each patient, definition of personalized "pro-active" PDTAs - Identification, in every AFT (Territorial Functional Aggregation ), of "expert" general practioners and provision of first-level diagnostic technologies - Identification of reference specialists - Structured reorganization of "Community of Practice" between primary care physicians and referral specialists - Design of an enabling information system to exchange of socio-health data and for the teleconsultation, telemedicine, remote control.