A continuity care program in chronic, complex and frail patients: the PRO-CCF study protocol

Background and aims. . The aging of the world population has inevitably led to an increase in the number of multi-morbid patients seeking healthcare assistance. The transition from hospital to territory is a particularly delicate moment. New treatment paradigms are required to optimize the continuity of care and to satisfy patients and caregivers' needs. The San Raffaele hospital signed an agreement with the VIDAS association for providing an integrated home care for chronic, complex and frail (CCF) patients, after hospital discharge. We aim at evaluating the effectiveness and satisfaction of an experimental transitional care program between hospital and territory, CCF patients. Methods. CCF patients discharged from an Internal Medicine Ward, and based on the geographical area of residence (covered or not by VIDAS assistance) will be divided into two groups: 1) receiving standard care 2) involved in the transition care program. The administration of PACIC questionnaire, to assess the eventual organizational improvement in the study group, will be performed at hospital discharge and at 6- and 12-month follow-ups. Conclusions. . If this innovative intervention proves to be effective, it will be able to improve the management of chronic, complex and frail patients, reducing the risk of negative health outcomes and diminishing the related healthcare expenditure.