Ateneo - UPO

The course on hospital-to-community continuity examines the organizational and care models that ensure seamless care transitions between the hospital, community services, and the patient's home. It focuses on managing individuals with complex care needs and chronic conditions, planning supported discharges, and coordinating care pathways through multidisciplinary collaboration. Furthermore, it addresses the nurse's role in case management, health and social care integration, the use of multidimensional assessment tools, and organizational and technological innovations—such as telemedicine—aimed at enhancing the quality, safety, and appropriateness of care.

Sandra Scalorbi - Yari Longobucco - Andrea Trentin, Infermieristica preventiva, di famiglia e di comunità, Mc Graw Hill - seconda edizione;
Cesarina Prandi - Pierluigi Badon, Assistenza infermieristica di famiglia e di comunità, Ed Casa Editrice Ambrosiana

The course aims to provide the skills to design, coordinate, and evaluate care pathways that ensure continuity of care across hospital, community, and home settings, with a particular focus on managing individuals with complex care needs.

Knowledge of the general principles of the nursing profession. knowledge of the ethical and ethical principles governing the nursing profession.

Lectures will be used to impart theoretical knowledge, alongside simulations and presentations of clinical cases and care scenarios, to plan interventions ensuring continuity of care between hospital and community settings.

Students with physical disabilities, Learning Disabilities or Special Education Needs can request specific services and tools via the Staff Sviluppo e Coordinamento Carriere e Servizi alle Studentesse e agli Studenti, consulting the University webpage: https://www.uniupo.it/en/services/servicesstudents-physical-or-learning-disabilities Students with disabilities, learning disabilities or special education needs, once they have contacted the University Staff, can refer to the tutor in charge of the course to define the examination modalities, concerning academic aspects.

The exam consists of a written test with multiple-choice questions designed to assess knowledge and understanding of the subjects comprising the Integrated Course.

1. Concepts of continuity of care
Definition and principles of continuity of care.
Integrated hospital-community organizational models.
Person- and family-centered care.
Appropriateness and clinical-care continuity.
2. Evolution of the healthcare system
Community-based care and service networks.
Health and social care integration.
The role of the community setting.
3. Care transitions
Supported discharge.
Discharge planning.
Continuity of information and clinical documentation.
Communication tools for professionals.

By the end of the course, the student should be able to:

design pathways for continuity of care;
coordinate the management of complex patients;
foster integration between hospital and community care;
use multidimensional assessment tools;
collaborate effectively within a multi-professional team;
evaluate the quality, effectiveness, and outcomes of care;
apply innovative organizational models for managing chronic conditions.