Beyond Silos aims to promote healthy lifestyles in order to reduce the
prevalence of age related chronic diseases in the general population.
“Beyond Silos” is aimed to address the issue of de-hospitalization by designing and implementing a network of services and facilities that is tailored upon the local context, to support the reduction of the cost of avoidable hospitalization by implementing an efficient and effective ICT system. These devices allowed the detection, transfer and monitoring of the clinical parameters that was stored at the hospital servers.
Chronic, multi-morbid patients include a heterogeneous population with a broad spectrum of health needs calling for a multidisciplinary approach, that takes in to account patients’ individual preferences, and ranges from clinical to socio-cultural and psychological perspectives.
Beyond Silos ICT tools allows tele-monitoring of patients, integrated with home social and healthcare services. This facilitates scale up to a larger number of patients of the same district, as well as to other districts.
The stakeholders are:
• University high specialty hospital personnel, including decision makers
• Local Health Agency ASL Salerno personnel, including decision makers
• Campania Region policy makers and decision makers
The target population is Older adults (Age>65) in home care, non-communicable chronic disease patients.
The scale up of Beyond Silos will require:
- Training of human resources
- Integration of digital solutions
- Update of the IT solutions available at central and home level
- Revision of the organization of current practice
An estimate of the cost has not been carried out yet in detail.
Evidence of success
Beyond Silos supports the reduction of the time of occupancy of hospital beds, by the delivery of integrated care at the home of patients. Once the Care Pathway is defined according to the specificities of the local setting, the hospital alerts the integrated care provider and discharge the patient from the hospital. The local network of nurses, territorial specialists, territorial pharmacists, nutritionists and rehabilitators will provide to patients the hospital care they need at their places.
Potential for learning or transfer
The practice is a pilot study of the CIP-ICT-PSP program that in Campania has added ICT based clinical and social assessments trough questionnaires and tele-monitoring to the existing web-based platform CUREDOM that is used for the management of Home Care. The project was funded by the Campania Region in the context of a contract for innovation companies. Magaldi Life, a leader SME in the home care sector in Campania, in collaboration with SimasLab, which also includes the San Giovanni di Dio e Ruggi d’Aragona University Hospital associated to design, test and implement the ICT-supported solution. 100 patients in an early hospital discharge were enrolled in home tele-monitoring.