Abstract
Introduction: Social and healthcare organisations are facing significant challenges in rebuilding care services after the COVID-19 pandemic, which were already under pressure due to demographic changes, including ageing and chronicity of the population and increased situations of dependency. These generate an increased number of hospital admissions, and in some cases longer stays due to a lack of social support at home.
Integrated health and social care systems can be at the forefront of providing a better response to these challenges, helping to maintain people’s autonomy to live in their own homes and remain independent for as long as possible.
In the development of new care models, active engagement of all stakeholders, including patients and caregivers, holds pivotal significance. Their input is vital to ensure the model aligns with real-world needs and is user-friendly.
Objective: The main objective of this study was to develop an innovative integrated health and social care model that incorporates home care services and technological support to enhance the transition from hospital to home for those elderly patients who lack the social support needed; with the ultimate goal to shorten hospital stays or avoid them when possible and improve patients’ wellbeing. This model was designed through a participatory design approach, involving care recipients, care providers, and all relevant stakeholders in the process to design a solution that is based on users’ needs.
Methods: A participatory design approach was employed to achieve the main objective of the study. Using design thinking and citizen participation techniques, the study was distributed across 4 phases: (1) Definition of the main target groups, carepathways and pathologies to focus on for the pilot, (2) understanding of the current pathways, the social and healthcare services ecosystem, and identifying patients, caregivers and healthcare professionals’ needs (3) online and in-person co-creation activities with patients, caregivers, healthcare and social care professionals, as well as home service providers, technology experts, and decision-makers to co-create the new integrated care model and service, (4) design of the final model and service to deploy a pilot for 18 months.
Results: As a result, a new integrated care service has been developed, based on users’ expertise and needs, to provide social & health home care support during the first 7-30 days post-hospital discharge.
The service encompasses four main elements that constitute this holistic support: (1) Daily support from a caregiver at home, and regular home monitoring by a technical multidisciplinary team; (2) A monitoring kit for remote health tracking and identification of warning signs; (3) A personal discharge folder containing self-care and prevention content with personalised recommendations for proactive engagement in their recovery; (4) A digital platform facilitating information management, alerts, and communication among stakeholders.
This innovative and integrated care approach aims to facilitate early return home, contributing to the patients’ recovery after hospitalisation while restoring autonomy and organising long-term support; ultimately enhancing patients’ well-being.