From home visits to telehealth,IRCCS San Raffaele patients can receive comprehensive care in the comfort and privacy of their own home for the:
Upon discharge, a private home rehabilitation pathway can be activated at our Facility, ensuring continuity of care through the careful supervision of the same multidisciplinary team that followed the patient during his or her hospitalization. The equipment and medical supplies needed to carry out the rehabilitation will be brought directly to your home.
Private multidisciplinary rehabilitative treatment and care can be activated by anyone who needs it either at home or at our locations on an outpatient basis, even independently of admission to our departments, though always based on the prescription of a pathology specialist and the clinical and logistical needs of the patient.
Telerehabilitation and Telemedicine with monitoring complement and integrate Patient care and treatment activities.
Access to the service
The ADI service, which is accredited with the Health System, has its operational headquarters in Rome at the IRCCS San Raffaele, Via della Pisana 235, and aims to provide integrated social-health services within the Asl Roma 3.
Integrated Home Care (A.D.I.) is a predominantly health care service, agreed upon with the Patient, relatives and family doctor, for a predetermined period of time, which allows citizens who need it to be cared for at home, with individualized programs, avoiding hospitalization and allowing the person to remain as much as possible in their usual living environment, or making early discharge possible. In this regard, “Integrated Home Care” is defined as that care for which a complex organization is formed, that is, a network work that coordinates and integrates the various professional figures such as: physicians, professional nurses, rehabilitation therapists and social workers, maintaining relations with specialists, day hospitals, organizing and booking examinations or consultations, procuring and providing the necessary materials and aids for home care, according to the detected needs.
The services, declined within the individual care plan, are provided by qualified staff with the specific professional qualifications, and are complementary to and not a substitute for the family caregiver ; they can therefore support and/or supplement existing and available family presences (relatives and/or their helpers), not replace them completely.
To whom it is addressed
A.D.I. is aimed at individuals with temporary or protracted non-self-sufficiency or reduced self-sufficiency resulting from critical conditions of socio-health or pathological need, and in particular Patients characterized by:
- Presence of a condition of partial or total non-self-sufficiency, temporary or permanent in nature;
- Presence of a nonambulatory condition;
- Non-transportability to outpatient health care facilities that can meet the person’s needs;
- Presence of support in the family/parental or informal network; presence of housing conditions that ensure the practicability of assistance, also acquired as a result of necessary actions to overcome any obstructive factors (example: removal of architectural barriers).
Ways of Activating the A.D.I. Service.
The General Practitioner/Family Paediatrician issues the user/family member a request for ADI activation, formulated on the Regional Prescription Book specifying the need for home care. After assessing the patient’s care needs, the Home Care Center (CAD) of one’s referring ASL draws up the Individualized Care Plan (IAP) and sends it to the service provider chosen by the patient or his or her caregiver. IRCCS San Raffaele at the time of the guest’s admission, provides for the conduct of a new interdisciplinary assessment aimed at the refinement of the PAI shared with the ASL, and the definition of the care and therapeutic objectives measurable in scheduled time periods during the period of care. The IAP is communicated in an understandable and appropriate way to the assisted person and his or her family members and/or guardians in order to progressively share the progress of the set goals, highlight with the help of professionals the achievement of the goals, or analyze any emerging critical issues. Fundamental is the figure of the GP, who collaborates with the team during the inpatient period in the continuous monitoring of the health conditions of the patient and provides pharmacological prescriptions and any specialist and diagnostic visits.
