Abstract
Tesino (population 2200) in the Province of Trento (PAT) is part of Italy’s National Strategy for “Inner Areas”, an innovative policy for development and territorial cohesion in isolated areas, characterized by the distance from the main hospitals and clinics, infrequent clinicians’ coverage, and the increase of an aging population with chronic diseases.
To counteract marginalization and demographic decline and to meet the health needs of the residents in Tesino, the Autonomous Province of Trento (PAT), with the support of TrentinoSalute4.0, a joint competence centre on digital health of the local Healthcare Trust (APSS), PAT and the research centre Bruno Kessler Foundation (FBK), is developing a new model of a decentralized clinic managed by a community nurse, linking people and clinicians with the support of telemedicine, in a stepped-care strategy. Within this context, the clinic also aims to engage the community and promote the empowerment of the patients in taking an active role in their health self-care.
The clinic is currently involved in remotely following up discharged patients from the hospitals and promoting, together with the local governments and main people associations, the use of TreC+, a free digital health platform that allows citizens to manage their clinical profile (currently covering around 30% of PAT population). TreC+ also enables the replacement of some in-person outpatient activities with remote assessments and remote visits. Within this ecosystem, TrentinoSalute4.0 is co-creating with clinicians an organizational model where the nurse-clinic can assist patients, in particular chronic elderly that more frequently need follow ups with the doctors, but have low digital competences, by supporting them during the tele-visits requested by clinicians and potentially measuring and sharing clinical data remotely (es: oxygenation level) using tele-cooperation. TreC+ also enables remote monitoring of patients (i.e. TreC Cardiology for Hearth Failure patients), a tool that the community nurse could use to act as a first step between patients and clinicians.
A collaboration between the community nurse-clinic and doctors (i.e. General Practitioners, Pediatricians and Specialist Doctors) needs an organizational change and an integrated digital system such as TreC+ platform, that takes into account the different professional roles and the specific needs of the region.
The community-clinic in Tesino is the first of several that are being planned to open in the region, and can also serve as a reference model for the new decentralized community health clinics that will probably be implemented elsewhere in the foreseen future.