Continuity of Care: A Multidimensional Vision for the Frail Patient

The work structures an innovative territorial hospital operating model based on the creation of a multidimensional geriatric and surgical team dedicated to frail surgical patients. The model analyzes the problems, combining the patient’s needs with the specialist hospital vision at the time of discharge, integrated with the findings of the territorial specialists. The analysis also takes into consideration the possible role of the Territorial Operations Centers, envisaged by Italian Mission 6 “Health” of the National Recovery and Resilience. In particular, the organizational model is analyzed with which the frail surgical elderly patient is inserted into a model of communicating vessels between the various settings, whose keystone of care remains a model of functional integration between the hospital and the territory. Particular attention is paid to the role of intermediate care in the optimal management of the needs of the frail surgical patient.