Since 2010, in the Apulian Region, a phase of reorganization and reengineering of territorial assistance in the entire system is taking place. This foresees, above all, the government of Diagnostic-Therapeutic-Welfare Pathways (PDTA) in the primary care context. The management model and, therefore, of care continuity is the so-called Desease and Care Management model. The fundamental element of this multidisciplinary approach, with strong integration of all different professional skills involved, is the generation of patients’ empowerment with the innovative support of the nurse – Care Manager. “Nardino Project” is inserted as part of this proposed welfare model and is based on caretaking of fragile people suffering from long-term pathologies. The strong integration with the Complex Associations of General Medicine, increases and redevelops the offer of territorial assistance becoming, therefore, the strength point that, added to the “taking charge”, ensures the continuity of the care and operates like a real “filter” for useless or improper emergency room intervention and hospital admission. The position of the so-called Care Manager, wished for by Nardino Project, takes the function of mediator of organization needs of the fragile person and his/her family, in order to avoid or procrastinate as much as possible the use of high complexity assistance settings. One of Nardino’s strongest point is Telecardiology, which offers the possibility of carrying out medical telemonitoring of patients with chronic-degenerative diseases (for example, heart failure, hypertension or respiratory failure) at medical offices, nursing clinics and/or patient’s house, reducing the discomfort of transport from the residence to the hospital of reference. Telecardiology is an area of additional service, not merely a substitution, of specialist services and hospitalization, which aims to strengthen the continuous and integrated taking in charge of the patient’s needs according to the specific pathology through computer technology and specific medical devices. In the Socio-Sanitary districts of Maglie, Campi Salentina, Veglie, Minervino and Spinazzola, A.Re.S Puglia has activated Telecardiology, a procedure involving the execution of electrocardiograms, ABPMs and cardiac Holters with “on line” specialist remote consultation through the use of equipment, directly applied to the patient by nursing staff. Examinations are sent to Cardio On Line Europe Telecardiology Operating Center (already in partnership with Apulia Region for the Telecardiology service in 118’s emergency since 2004), monitored by specialized operators and cardiologists for 24 hours a day and for 365 days a year, where real-time diagnosis are sent to the place where the patient is assisted or to the nearest hospital centre, to facilitate care intervention when the patient arrives to the place. In addition to ensuring new services and greater protection for patients who have been taken over by the Care Manager to improve chronic disease control and limit hospital treatment use, Cardio On Line Europe Telecardiology service also offers technologies and services, solutions for medicine on the territory, together with monitoring, prevention tools and prescriptive indications on a remote basis.

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