Italian Pilot Project

Italian pilot project

The Palazzolo Institute, located in Milan (Italy), is the largest center of the Don Carlo Gnocchi Foundation offering care and assistance services to older adults. The Institute offers both health and social services for residential as well as community-based patients (home care services). All the services are integrated to offer a care program that is shared with patients and caregivers. The Institute has implemented specific discharge pathways that integrate the health care units with other services, including community-based services. Discharges are programmed to follow the patient and progressively facilitate their return home.

The Palazzolo Institute offers the following services:

  • Acute and sub-acute care units
    • The Acute Care Unit (20 beds), offers internal medicine services and support to the patients at the nursing home of the Institute as well as to patients at the home community services.
    • The Sub-acute Care Unit (20 beds), takes care of patients needing health support after an acute event or suffering from chronic diseases without preeminent clinical instability.
  • Rehabilitation units
    • Neurological and Orthopedic Rehabilitation (25 beds).
    • Pulmonary rehabilitation (15 beds).
    • Intermediate care unit (75 beds), that takes care of patients in the intermediate phase between the discharge from the acute or sub-acute unit and their return home.
  • Residential long-term care units
    • Nursing Home (517 beds), within which there is a special Alzheimer Unit counting 30 beds devoted to patient suffering from dementia and behavioural symptoms.
    • Chronic Consciousness Disorders Unit (29 beds).
    • Neurodegenerative diseases Unit (18 beds), for patients suffering from Multiple Sclerosis and Amyotrophic Lateral Sclerosis.
    • Hospice (10 beds), for terminally ill patients counting.
  • Residential and semi-residential social units
    • Day centre for elderly, which can offer daytime hospitality to 30 frail older adults.
    • Sheltered house for frail older adults (named Casa Aurora). The house, that can host up to 11 people, is an “Assisted Living Facility” that hosts people with functional limitation in the activities of daily living.
  • Community and home-care services
    • Integrated home care assistance (in italian Assistenza Domiciliare Integrata – ADI), a set of health and specialized home care services offered to those people unable to benefit from the standard outpatient services offered by the Institute. The Local Health Authority evaluates the request, defines an individual project and gives the patient a voucher for a set of services (medical services, infirmary services, rehabilitation services and assistance for basic daily life activities). A specific service is available for home care assistance of people with dementia (named ADI demenza).
    • Open Nursing Home (RSA Aperta in Italian), an experimental service aimed at to bring the services of the Nursing Home to the patient’s home. The process is similar to the integrated home care assistance but with a tighter integration of social and medical interventions.
    • Social Home care Services, a set of services addressed to frail elderly people living alone (e.g. housekeeping, help with bureaucratic and administrative procedures, help for medical exams, help on daily living tasks, support in toileting, in meal preparation, in acquiring drugs or foods). Within frame of social home care services, a specific service has been activated named “Custodi Sociali“. The service employs a number of community operators in the areas of Milan with the higher concentration of frail people (mostly elderly people living alone). The main activities of this service are related to monitoring the territory (in cooperation with the operators of social housing) to detect expressed and unexpressed needs of the population; exploiting of the resources on the local community; supporting the people in the use of services and resources in the local community; activating formal and informal networks; facilitating the active participation in social activities and organizing social and entertainment events in the available facilities and spaces.
  • Outpatient services
    • Specialists outpatient services in the following areas: geriatrics, angiology, cardiology, general surgery, endocrinology, internal medicine, neurology, ophthalmology, orthopedics, otolaryngology, psychiatry, urology, dermatology, psychiatry, gastroenterology, oncology, pneumology, radiology, laboratory analysis, dentistry and special needs dentistry, pain treatment and acupuncture.
    • Outpatient rehabilitation service, at the Institute and at home, providing rehabilitation in the neurology, orthopedics and pneumology areas.
 

The following tables summarize the activities and the number of services provided in the year 2014.

 

Beds

People/year

Acute and sub-acute care units

73

753

Rehabilitation units

115

1.445

Residential long-term care units

605

1.210

Residential and day care social units

41

169

 

 

People/day

Contacts/year

Community and home-care services

1.236

106.802

Specialist outpatient services

68

18.481

 

Diagnosing MCI and Dementia in Palazzolo Institute

The estimated number of people suffering from dementia in Italy in 2012 has been 1.272.317 and this represent 2.09% of total population. In the city of Milan the Local Health Service estimated that people with dementia, among those aged 65 or older, are about 20,000 which means a prevalence of 6.3%. The prevalence of MCI in Italy has been estimate around 6 % in people aged 65 or older but a lot of heterogeneity have been reported.

In the Palazzolo institute services for people with cognitive impairment are organized along an ideal temporal line which follow the different stages of the illness (from the onset of the first symptoms to the terminal stage of the disease):

  • Diagnostic suspect: MCI and dementia are characterized by an insidious onset of cognitive symptoms. Usually both the patient and the family members perceive a behavioral change in the everyday life but they have trouble to link that to a cognitive impairment at the beginning. At this stage, often the patient is not referred to a specialized service for the diagnosis of MCI or dementia, and when the patient interact with his General Pratictioner or with a specialist, often there is a misdiagnosis (e.g. mood disorders) or a vague diagnosis (cognitive decline) that delay a correct diagnosis and care process of several years.
  • Diagnosis: usually, a correct diagnosis is made by a Memory clinic (Unità Valutazione Alzheimer or UVA in Italian). At the Palazzolo Institute, a patient can be referred to the Memory clinic by his/her General Practitioner, by another Specialist or by a Geriatrician of the Institute who saw the patient for another issue. At this point, the Memory clinic starts the assessment protocol for MCI and Dementia, a standardized workup to reach at a diagnosis as accurate as possible. After the diagnosis, a drug therapy could be implemented, if possible, and a follow-up is scheduled. At this stage, the specialist of the Memory clinic can interact with other internal services to start a home-care service, a case-management or a psychological counseling to caregivers, if needed.    
  • Clinical path: Once a diagnosis has been made, the patient is followed-up at regular intervals and, if needed, on demand. The variables that influence the quality and quantity of clinical care in this phase are related to the adjustment of the drug therapy, the presence of unexpected clinical events or the presence of behavioral disturbances related to dementia. The network of services available in our Institute can manage the majority of patient’s clinical issues.
  • Care path: The Care path develops in parallel to the Clinical path. It will have a different composition depending on the presence of cognitive disability only or both cognitive impairment and behavioral disturbances. At present, care path of patients is usually organized by their family members or caregivers in autonomy in reference to the progressive reduction of patient’s autonomy. If patients are cared for by the Memory clinic of the Institute, care path can be managed by other internal services whit several home-based and facility-based services. From 2015 two new home-care services devoted to patients with dementia are available: ADI Demenza and RSA Aperta (see above).
  • Domestic care system breakdown: the breakdown of the domestic care system can be caused by several reasons (e.g. clinical or functional deterioration, evolution of behavioral and psychological symptoms of dementia, falls, malnutrition, dysphagia, etc.). Usually, this is the phase at which caregivers look for the assistance of formalized social and health services. At this stage the improper use of emergency or hospital services is frequent. This improper use of health services comes from the lack of correct information about dementia on the part of caregivers or from the absence of specialized home-care services promptly available. Other reasons of breakdown are related to caregiver issues and stress (e.g. caregiver burnout, temporary unavailability of principal caregiver, caregiver holidays, or sudden unexpected deterioration of patient autonomy after an acute clinical event). In these last cases, the use of facility-based care services can solve the breakdown.
  • Complete disability/end-of-life: the last stages of life of dementia patients (CDR score 4 and 5) are usually managed in nursing homes or, seldom, in end-of-life care services. It is also possible to manage patients at this stage at home by services like ADI and ADI palliative care.