Continuity of health care in patients with chronic respiratory insufficiency: a macro-model of care integration between hospital and home

The increasing importance of chronic diseases brings with it the need to develop new organizational models of healthcare in which the patient becomes a partner in the process, contributing to almost every decision or action level. In this paper, we define a macro-model of integration between hospital and home care aimed at improving the clinical pathway efficacy for patients with chronic respiratory insufficiency (CRI). This model is subdivided into two phases: a) what is needed to create a network of services dedicated to patients with CRI; b) the pathway defined with flow-charts and tables of activity/professional skills/responsibility. The model, respecting the principles of disease management, represents the assistential pathway for patients with CRI within the integration process between hospital and home care.