Ricerc@Sapienza

The burden deriving from non-communicable diseases (NDCs) and multi-morbidity is currently challenging the capacity of the Italian National Health System (NHS) to respond to the health needs of its rapidly aging population. A change in approach to the management of NCDs is needed, focusing on strengthening primary health care (PHC) and PHC professionals and on empowering individuals in managing their disease and preventing complications thus improving their quality of life. The current project has the goal of structuring and evaluating the effectiveness of an innovative multifactorial intervention, led by family nurses, aimed at improving self-care skills of chronic patients in their living environment and context. A multicenter randomized clinical trial will be carried out involving trained Family Health Nurses in the administration of an experimental intervention specifically developed for the purpose of the project, based on a literature review, consisting of the following elements: Information, Training, Accessibility, Care-givers, Assessment (ITACA). At least 148 patients will be enrolled will during their hospital admission and randomized 1:1 into control and experimental groups. The primary outcome will be the change in the levels of quality of life and self-care. Secondary outcomes measures will include mortality and hospital utilization (readmission rate - type and cause of admission, length of hospitalization - unplanned access of care - ER, GPs). Outcomes will be assessed both in the experimental and in the control group through repeated measures over the 12-months follow-up period (baseline, 1,3,6,12 months). The project will contribute to generating evidence on the effectiveness of a family nursing model for the global management of chronic diseases. Based on an assessment of its effectiveness, the ITACA intervention could be extended also to other care settings.