The Individual Care Plan (ICP): proposal of a model to improve the communication between hospital and primary health care services

Background. Patients admitted to Internal Medicine wards are frequently defined complex patients for their severe symptoms, comorbidity, disabilities and socioeconomic critical conditions. Once the clinical stability is achieved, they may be discharged from hospital and to ensure continuity of care they require personalized arrangements providing medical, nursing and social supports in primary health care services. The aim of this study is to propose a model of Individual Care Plan (ICP) for complex patients. Methods. The model was developed starting from the assessment of multidimensional needs according to the International Classification of Functioning, Disability and Health (ICF) of World Health Organization (WHO), and defining for each detected need the goals, the related interventions, the professionals involved and the devices prescribed for personal use. Results. This paper presents the model in a practical manner, indicating the ICP of a complex patient. The ICP, divided into three sections (clinical, care and environmental) describes all the aspects of cure and care to be delivered in the primary health care services. Conclusions. The ICP that we proposed is a dynamic tool aimed to ensure the continuity of care and cure after hospital discharge, to facilitate the communication between hospital and primary health services and in the different settings of care in which the patient transits, to monitor the evolution of multidimensional needs over the time. Finally the ICP is useful in evaluating the costs, results and outcome of care and cure of a patient.