Position paper ANMCO in collaboration with Italian Alliance for Cardiovascular Rehabilitation and Prevention (ITACARE-P): 'the management of hospital discharge'.

Figures

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  Figure 1. The phases of communication from the beginning of hospitalization to discharge. The sequence is determined by the progressive relevance of the objectives to be achieved, with a gradual narrowing of the focus on the patient and with a selection of information that takes into account the patient’s priorities and not only the disease. For each phase, the main objective and the operational sub-objectives are indicated; in addition, the communication skills that the physician must possess in order to achieve them are reported. Achieving the objectives of one phase is a pre-requisite for moving on to the subsequent phase and thus for arriving at good communication at discharge.

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  Figure 2. Management of the discharge process by the multidisciplinary assessment team.

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  Figure 3. Operational flow chart for the management of ‘referral’ and ‘no referral’ to cardiac rehabilitation at discharge from an acute care ward. Criteria for taking charge of the patient are as follows: availability of a territorially compatible cardiac rehabilitation centre, availability of an appropriate care setting (inpatient or non-inpatient), time to taking charge, and consistency between the acute hospital discharge summary and the rehabilitative hospital discharge summary, ensured in accordance with the 2021 Ministerial Decree. Best possible alternative are as follows: oriented towards the main objectives of maintaining clinical stability, reducing residual risk, reducing disability, lifestyle modification, and psychosocial support (e.g. structured outpatient follow-up, a shared care pathway with the GP, integrated rehabilitative home care, activation of the family and community nurse, referral to health gyms with a structured physical exercise programme, referral to smoking cessation centres, and counselling services with educational and psychological activities). In case there is a need to continue hospitalization in facilities with a lower intensity of care, appropriate…

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  Figure 4. Management of a clinical pathway dedicated to telemedicine. GP, general practitioner; BP, blood pressure.