Early Identification of Post-Demission Setting

Discharge is a crucial phase of the care plan during which professionals must find a common thread to coordinate the patient’s entire clinical care process. This guarantees assistance that meets the criteria of appropriateness, efficiency, and fairness, placing the patient at the center of the path. The nurse’s role does not end with hospitalization; they are responsible for developing a personalized care plan to be guaranteed at home. The difficulty in discharging patients in the hospital setting, reduced periods of hospitalization, frail patients often unprepared to face the return home, post-discharge complications, lack of knowledge of the patient, and frequent rehospitalizations are all reasons that make it necessary to plan individually to ensure continuity of care. Continuity of care is not just the continuity of service but taking charge of the patient. This ensures a discharge where services and structures interact to offer the single patient the most suitable care in relation to their needs and resources. “The nurse informs, involves, educates, and supports the person concerned and, with their free consent, the reference persons, to encourage adherence to the treatment path and to evaluate and activate available resources” (Chap. IV, Article 17 of the 2019 Code of Ethics for Nurses). “In professional action, the nurse establishes a relationship of care, also using listening and dialogue. It guarantees that the assisted person is never left in abandonment, involving, with the consent of the interested party, their reference figures, as well as other professional and institutional figures. Relationship time is care time” (Chap. I, Article IV of the 2019 Code of Ethics for Nurses).