COVID-19 and the dutiful rethinking of care and assistance pathways

How can the Italian healthcare system start again? What directions must we take to improve it, after the COVID-19 emergency? Maria Giulia Marini, Innovation and Scientific Director of ISTUD Healthcare Area, summarises the problems occurred from a broad perspective. Starting from discussing the 2014 Balduzzi Decree, she proposes some possible actions to improve the Italian healthcare system: mass-screening, strengthening territorial medicine, enhancing innovative good practices such as telemedicine and, finally, taking care of our ecosystem by adopting new forms of clean energy as soon as possible. We offer the English translation of the article, published on the Italian newspaper Il Sole 24 Ore Sanità. 

The approving of the Balduzzi decree (158/2012) opened to the National Healthcare System reform on the reorganisation of primary care, including territorial care and general medicine, within the Italian Regions. Territorial care was to be strengthened by defining the general practitioner as the “keeper of people’s health”, to be carried out in association and with other territorial specialists. 

Despite this central reform, Italian Regions took different paths. Veneto, Tuscany, and Emilia Romagna focused on the territory. In contrast, almost all the others have strengthened the hospital-centric culture, for the management of acute and chronic diseases and the RSA*-centric culture for the elderly care. Both hospitals and RSA have often escaped territorial collaboration with general practitioners and social services. In Lombardy, as in other Regions, private and accredited private clinics have grown up ready to give expert answers to health needs on non-communicable diseases, (e.g. tumours, cardiovascular diseases), but cutting intensive care beds, considered costly (with an estimated daily cost from 1200 to 1500 euro/day).

But which patients were treated in hospitals? In the last eight years, the hospital has mainly treated patients from a multi-professional, multidisciplinary and technologically advanced area. In doing so, the hospital has lost its sense of structure for acute severe cases, cutting the number of beds and becoming an outpatient facility: the 2012 data indicated 12.5 intensive care beds per 100,000 inhabitants, unlike Germany which had 29.2 beds per 100,000 inhabitants. The data on hospitalisation facilities for the elderly in the Rsa indicated, in 2015, the presence of 12,828 institutions of which 64%, concentrated in Northern Italy, 25% in the Centre and 10.4% in the South. 

Treatment for chronic and degenerative pathologies was provided, mainly in hospital centres, with a strong push for the frail elderly in RSA. Social medicine services, which included infectious diseases, were also inadequate, both at a territorial and hospital level.

COVID -19 and the dutiful rethinking of care and assistance paths

Little we know about this virus, but one thing is likely and discouraging: to date, 30 to 50% of people with COVID-19 die in intensive care. Increasing the number of beds in intensive care is correct so that ethical choices no longer have to happen because of scarce resources, on who to intubate according to residual life expectancy: still, this works in an emergency rather than in organisational management of the problem. 

And here we resume “Disease Management”: a process of screening, prevention, diagnosis, treatment and rehabilitation on the territory – possible hospitalisation – and re-integration in the territory. What the computational epidemiologist Vespignani has condensed in the rule of the three T, Testing, Tracing and Treating: (do) tests, swabs and antibody tests, trace, reconstruct all possible contacts of infected people and isolate them (send them to hotels and barracks, not at home to infect other family members), treat them as much as possible in early prevention as the first symptoms appear. 

In countries and regions where the territory has carried out mass screening for COVID-19, isolated the infected, quarantined families, and given drug treatment, the use of intensive care has been lower.

Five factors to report

  1. General medicine, made safe with medical devices, together with the social services of the municipalities, has a fundamental role in citizenship education, tracking, prevention and patient management. 
  2. Arriving in intensive care is too late, because in many cases, the pathology is manageable at home, through tampons, medicines, medical devices, and social services that bring lunch and dinner to the sick. 
  3. Institutes such as RSA and hospitals are places where infections are deflagration: in RSA the deaths have been atrocious, without even the humanity of anaesthesia. Other models of care for the elderly should be found. 
  4. Telemedicine by general medicine, which was first opposed because not reimbursed by DRG**, has assumed a strategic role, both for the sending of prescriptions and examinations by telematic means and for the management of the visit.
  5. There is a possible correlation between atmospheric particulate matter and the presence of COVID-19: people have fallen more ill in industrialised areas with high levels of nitrogen dioxide. The promotion of new forms of energy to support industrial processes can no longer be delayed.

What indications to give 

  • Using good practices of winning territorial services towards COVID-19.
  • Investing in mass screening with swabs.
  • Carrying out communication campaigns employing posters with drawings and explanations in several languages on precautionary measures.
  • Sending a letter to the frail elderly at home for the creation of a “shield of protection”, i.e. call for help with medicines, medicines, social services, shopping, laundry.
  • Enhancing home care, with the family carer, and resort to RSA as the ultimate solution.
  • Developing telemedicine (access, use, quality and human touch).
  • Develop trauma management protocols for health workers and quarantined people.
  • Defining zones of air safety concerning the particulate that increases the risk of infection for COVID-19.

Patients and citizens have been left alone, at the mercy of media and social media communicating the opinions and publications of scientists and politicians. None of us received a personalised letter of precautionary measures at home. And as stated by the Italian Society of Neuro-Psycho-Pharmacology, one in three people already have or will have anxiety or depression as a result of lockdown. We need rationality and empathy to cure us and our health care.

*RSA: nursing residence for elderly people.

**DRG: Diagnosis Related Group system.

Maria Giulia Marini

Epidemiologist and counselor in transactional analysis, thirty years of professional life in health care. I have a classic humanistic background, including the knowledge of Ancient Greek and Latin, which opened me to study languages and arts, becoming an Art Coach. I followed afterward scientific academic studies, in clinical pharmacology with an academic specialization in Epidemiology (University of Milan and Pavia). Past international experiences at the Harvard Medical School and in a pharma company at Mainz in Germany. Currently Director of Innovation in the Health Care Area of Fondazione ISTUD a center for educational and social and health care research. I'm serving as president of EUNAMES- European Narrative Medicine Society, on the board of Italian Society of Narrative Medicine, a tenured professor of Narrative Medicine at La Sapienza, Roma, and teaching narrative medicine in other universities and institutions at a national and international level. In 2016 I was a referee for the World Health Organization- Europen for “Narrative Method of Research in Public Health.” Writer of the books; “Narrative medicine: Bridging the gap between Evidence-Based care and Medical Humanities,” and "Languages of care in Narrative Medicine" edited with Springer, and since 2021 main editor for Springer of the new series "New Paradigms in Health Care."

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