Definition and Testing of a New Model of Clinical Governance Based on the Integration of Tools Such as Health Technology Assessment, Clinical Practice Guidelines, Clinical Pathways, and Healthcare Performance Measurement for Planning, Implementation and Management of Healthcare Interventions in Different Settings - INTEGRATE-HEALTH-GOV - Geriatric Telemanagement of HEALTH Conditions in Nursing Home Residents Recently Discharged From the Hospital GET HEALTH-I

The GET HEALTH-I is a before and after study, consisting of both a retrospective and prospective component. The retrospective component of the study includes nursing home residents in the Marche region (Italy) who are readmitted to the nursing home after a hospital discharge, before the implementation of geriatric telemanagement. The prospective component, includes nursing home residents who are readmitted to the nursing home after a hospital discharge and are managed with the geriatric telemedicine intervention in addition to usual care. The primary objective of the study is to develop a geriatric co-management governance model using telemedicine for elderly patients with multimorbidity discharged from the hospital to nursing homes.The model will integrate geriatric specialists with nursing home staff and general practitioners.

A secondary objective of the study is to measure the performance of the model in terms of effectiveness and cost-effectiveness. In particular, an evaluation will be conducted on the effects of implementing the geriatric telemanagement governance model on the risk of hospitalization, geriatric syndromes (falls, delirium, pressure ulcers), number of medications, and inappropriate prescriptions. Adherence to the intervention by GPs and nursing home staff, satisfaction and perception of utility, costs, healthcare resource utilization, and cost-effectiveness will be evaluated.