Department of Primary Care and Intermediate Care

The Department of Primary Care and Intermediate Care acts as the technical coordination of the UU.OO.CC. on the territory that develop the main district functions. It works in favour of people who, due to age or specific pathology, are in a particularly fragile condition and, for this reason, need assistance for the person in their place of life.

The main function is that of production: that is, the provision through the territorial services of first-level services in order to guarantee the essential levels of assistance with regard to the territorial competences of basic health care present in the health centers spread throughout the territory. The territorial services are divided into complex operational units in turn divided into simple operational units; a fundamental tool of the activities of the territorial services is represented by the taking charge of weak or chronic subjects in order to guarantee through the therapeutic and assistance diagnostic pathways a continuous and adequate control of the trend of the pathology to which the citizen is affected. These paths that involve taking charge of the patient are carried out through the Health Houses.

In line with the Operational Plans of the Lazio Region, three Health Houses are active in our territory: Pontecorvo, Atina and Ceprano and those of Ceccano, Veroli and Ferentino are scheduled for 2017, while in Anagni there is a Health Centre.

The priority function of the Department is to guarantee the population an overall health care response, which is able to provide adequate basic care responses and to activate ordinary and intensive specialist assistance lines where they are necessary.

It therefore acts as an essential operational filter hub for hospital care.

At the same time, another function of the Department is to offer the continuum of care to specific and vulnerable targets of the general population, in connection with the strategic indications and network opportunities provided by the Social Health Integration Unit.

The main targets of the Department are therefore:

general population, for basic and specialist care;
fragile and/or vulnerable population:
- childhood and family;
- elderly people;
- disabled people;
- prisoners;
- immigrants.

General Practitioners and Paediatricians of Free Choice play a central role in the entire care process. The Department is therefore called upon to define the paths of care that ensure, on the one hand, continuity of care and, on the other, the contribution and specialist advice to basic medicine. To this end, the creation of Health Houses contributes, as intermediate structures aimed at guaranteeing assistance to the person and the execution of medium-low medicalization clinical-care procedures for the appropriate management of chronic-degenerative diseases, momentarily decompensated or exacerbated, which need monitoring, associated with conditions of variable social risk. In the Health Homes, the General Practitioners, the Medical Guard, nursing staff, hospital medical managers and internal affiliated specialists, social workers operate.

With regard to the developing population, the woman and the family, the Department plays the role of ensuring a unitary approach to protecting their health with a view to providing comprehensive assistance at the different stages of the life of the family and its components. It governs the Network of Family Consultants, of the Health Services of the Evolutionary Age; it collaborates, jointly with the Socio-health Integration Unit, with the Local Authorities for the socio-health programs aimed at families and minors with psychophysical and social difficulties. It develops the supply network in a continuum between promotion and monitoring of healthy development in childhood and adolescence and taking charge, at different levels of intensity, of cases presenting pathological conditions. The early diagnosis of disorders is therefore central to an adequate and correct socio-health action in developmental age.

It collaborates with other company structures on issues of common interest, with particular regard to adolescence and immigration, for which it coordinates with the Mental Health Department.

The elderly who are not self-sufficient and the disabled represent the population that, in priority to others, needs continuity of care and a constant intensity of care. Home care, rehabilitation, assisted living constitute the levers of assistance intended as support, temporary or permanent, to the individual and the family to promote the recovery of functional autonomy or to develop residual or potential autonomy. The Department is therefore the place of operational and functional connection of the entire process of taking charge and care of the patient with temporary or chronic disability, from the moment of evaluation (UVMD) to the moment of assistance to the person and the family, including prosthetic and rehabilitative assistance.

Another line of intervention is taken pursuant to the Presidential Decree of 1 April 2008, relating to the governance and management of health care in prisons, with the coordination of basic, specialist and nursing health care activities at the three prisons (Paliano, Cassino, Frosinone).

Another line of intervention is aimed at the other large segment of the population that is at risk of social marginality and has a high risk of health pathology, represented by the foreign population. This constitutes more than 4% of the general population, with a constantly increasing trend. Specific health care must be modulated in relation to the cultures to which they belong and to the particular problem given by the estrangement from the places of origin, considered an important risk factor for the onset of pathology.

Within the Department, the Rehabilitation Unit is included, which will guarantee the management of all the rehabilitation assistance interventions provided at the territorial operational structures and at the acute care hospitals, activating an integrated Hospital/Territory care path aimed at safeguarding the subject with rehabilitation needs, in compliance with the appropriateness of the interventions to be provided, the most appropriate settings and the appropriateness of the expected times; it will implement intervention procedures and operating models in the hospital environment capable of reducing, already in the hospitalization phase, the possibility of the onset of residual disabilities; it will manage in the hospital environment, through the operational tool identified in the company Rehabilitation Evaluation Unit, the application of the evaluation procedures envisaged for the identification of the rehabilitation needs of the patient on discharge, the level of his residual disability as well as his degree of clinical instability, identifying suitable operational settings and consequently activating the company and accredited operational structures involved; it will evaluate, to the extent of its competence, the assistance/rehabilitation needs in the territorial area within the company Multidimensional Evaluation Units.

The Department of Primary Care and Intermediate Care ensures the unity of activities through:

collaboration in the formulation of memoranda of understanding and operational protocols, defined by the Sociosanitary Integration Unit, aimed at developing support actions for fragile subjects in protected discharge, also through organizational-professional agreements with the Hospitalization Structures for the implementation of protected discharge, in agreement with other company bodies;
the coordination and direction of health services for patients suffering from disabling diseases and/or complex care needs and/or impairment of personal autonomy;
the direction of support activities to the General Practitioner to ensure continuity of care and to implement a personalized intervention plan for patients with complex and/or non-self-sufficient care needs;
the technical-organisational address of the residential care services (Hospice) relating to Primary Care;
the technical coordination of district prescription, authorization, supply and use activities, archiving of health and operational information, devices, prostheses and health aids;
the implementation of the lines of activities concerning family and paediatric consultants
an implementation of the lines of activity of Forensic Medicine also with regard to the management of prosthetic care.