This study addresses the management of chronic heart failure within community healthcare settings, a growing challenge associated with population aging and the increasing prevalence of chronic diseases. Consistent with the principles of the Italian Ministerial Decree 77/2022, ESC Guidelines, and regional Care Pathways (PDTAs), the study highlights the strategic role of telemedicine and the Family and Community Nurse (FCN) in ensuring continuity of care, home monitoring, and integration between hospital and community services. The aim of the study was to develop and test a standardized operational model for the home-based management of patients with chronic heart failure, integrating clinical monitoring, multidimensional assessment, therapeutic education, and nursing decision support. In addition, a structured documentation toolkit and two algorithms were developed: one for generating clinical alerts and another for assessing patient eligibility for telemedicine pathways. A pilot methodological study was conducted involving 17 patients with chronic heart failure followed by Family and Community Nurses within the Local Health Authority of Pesaro-Urbino (Marche Region, Italy). Patients were assessed at baseline, 3 months, and 6 months using multidimensional evaluation tools, validated scales, and a home-monitoring diary. Data were processed through a dedicated database incorporating a traffic-light alert system and a telemedicine eligibility algorithm. The results showed overall clinical stabilization, with most patients maintaining their NYHA functional class and demonstrating improvements in several clinical and care indicators, including dyspnea, peripheral edema, blood pressure control, and vital sign stability. Patients' self-monitoring skills also improved, increasing from 58.8% at baseline to 76.5% at the final follow-up, together with a greater ability to recognize early signs of clinical deterioration. The eligibility algorithm identified 94.1% of participants as suitable candidates for telemedicine services, while the alert system demonstrated strong consistency with observed clinical events and the corresponding care interventions implemented. In conclusion, the proposed model proved to be feasible, sustainable, and consistent with national organizational guidelines. The findings suggest that the effectiveness of telemedicine depends not only on the availability of digital technologies but also on standardized care processes, decision-support tools, and healthcare professionals equipped with clinical, educational, and digital competencies. The Family and Community Nurse emerged as a key professional in the community management of heart failure, promoting continuity of care, patient education, proactive monitoring, and early identification of clinical instability. Despite the limitations of a small pilot sample, the study provides a solid methodological foundation for the future implementation of telemedicine services within the regional healthcare network of Marche and for the development of innovative and sustainable chronic care models. Keywords: heart failure; telemedicine; telemonitoring; Family and Community Nurse; continuity of care; chronic disease management; community healthcare.
Lo studio affronta il tema della gestione territoriale dello scompenso cardiaco cronico, una delle principali sfide legate all'invecchiamento della popolazione e all'aumento delle malattie croniche. In linea con il DM 77/2022, le Linee Guida ESC e i PDTA regionali, viene evidenziato il ruolo strategico della telemedicina e dell'Infermiere di Famiglia e Comunità (IFoC) nel garantire continuità assistenziale, monitoraggio domiciliare e integrazione ospedale-territorio. L'obiettivo è stato sviluppare e testare un modello operativo standardizzato per la presa in carico domiciliare dei pazienti con scompenso cardiaco, basato su monitoraggio clinico, valutazione multidimensionale, educazione terapeutica e supporto decisionale infermieristico. Sono stati inoltre realizzati un kit documentale e due algoritmi, uno per la generazione di alert clinici e uno per valutare l'idoneità del paziente ai percorsi di telemedicina. È stato condotto uno studio pilota su 17 pazienti seguiti dall'IFoC nell'AST Pesaro-Urbino. I pazienti sono stati valutati al basale, a 3 e a 6 mesi mediante strumenti multidimensionali, scale validate e un diario domiciliare di monitoraggio. I dati sono stati elaborati attraverso un database dedicato con sistema di alert semaforico e algoritmo di eleggibilità alla telemedicina. I risultati hanno mostrato una sostanziale stabilizzazione clinica, con mantenimento della classe NYHA nella maggior parte dei pazienti e miglioramento di diversi indicatori assistenziali, tra cui dispnea, edemi periferici, controllo pressorio e stabilità dei parametri vitali. È inoltre aumentata la capacità di automonitoraggio dei pazienti, passata dal 58,8% al 76,5%, insieme alla capacità di riconoscere precocemente i segni di peggioramento clinico. L'algoritmo di idoneità ha identificato il 94,1% dei soggetti come candidabili alla telemedicina, mentre il sistema di alert ha dimostrato una buona coerenza con gli eventi clinici osservati e con gli interventi assistenziali attivati. In conclusione, il modello sviluppato si è dimostrato sostenibile e coerente con gli indirizzi organizzativi nazionali, evidenziando come l'efficacia della telemedicina dipenda non solo dalla disponibilità delle tecnologie, ma anche dalla presenza di processi strutturati, strumenti decisionali e professionisti adeguatamente formati. L'Infermiere di Famiglia e Comunità emerge come figura centrale nella gestione territoriale dello scompenso cardiaco, contribuendo alla continuità assistenziale, all'educazione terapeutica e all'identificazione precoce delle situazioni di instabilità clinica. Nonostante il campione limitato, lo studio fornisce una solida base metodologica per lo sviluppo futuro dei servizi di telemedicina nella Regione Marche. Parole chiave: scompenso cardiaco; telemedicina; telemonitoraggio; Infermiere di Famiglia e Comunità; continuità assistenziale; gestione della cronicità; assistenza territoriale.
Telemedicina e continuità assistenziale: proposta di un modello predittivo digitale per lo scompenso cardiaco oltre le criticità attuative
AMBROSINI, SARA
2025/2026
Abstract
This study addresses the management of chronic heart failure within community healthcare settings, a growing challenge associated with population aging and the increasing prevalence of chronic diseases. Consistent with the principles of the Italian Ministerial Decree 77/2022, ESC Guidelines, and regional Care Pathways (PDTAs), the study highlights the strategic role of telemedicine and the Family and Community Nurse (FCN) in ensuring continuity of care, home monitoring, and integration between hospital and community services. The aim of the study was to develop and test a standardized operational model for the home-based management of patients with chronic heart failure, integrating clinical monitoring, multidimensional assessment, therapeutic education, and nursing decision support. In addition, a structured documentation toolkit and two algorithms were developed: one for generating clinical alerts and another for assessing patient eligibility for telemedicine pathways. A pilot methodological study was conducted involving 17 patients with chronic heart failure followed by Family and Community Nurses within the Local Health Authority of Pesaro-Urbino (Marche Region, Italy). Patients were assessed at baseline, 3 months, and 6 months using multidimensional evaluation tools, validated scales, and a home-monitoring diary. Data were processed through a dedicated database incorporating a traffic-light alert system and a telemedicine eligibility algorithm. The results showed overall clinical stabilization, with most patients maintaining their NYHA functional class and demonstrating improvements in several clinical and care indicators, including dyspnea, peripheral edema, blood pressure control, and vital sign stability. Patients' self-monitoring skills also improved, increasing from 58.8% at baseline to 76.5% at the final follow-up, together with a greater ability to recognize early signs of clinical deterioration. The eligibility algorithm identified 94.1% of participants as suitable candidates for telemedicine services, while the alert system demonstrated strong consistency with observed clinical events and the corresponding care interventions implemented. In conclusion, the proposed model proved to be feasible, sustainable, and consistent with national organizational guidelines. The findings suggest that the effectiveness of telemedicine depends not only on the availability of digital technologies but also on standardized care processes, decision-support tools, and healthcare professionals equipped with clinical, educational, and digital competencies. The Family and Community Nurse emerged as a key professional in the community management of heart failure, promoting continuity of care, patient education, proactive monitoring, and early identification of clinical instability. Despite the limitations of a small pilot sample, the study provides a solid methodological foundation for the future implementation of telemedicine services within the regional healthcare network of Marche and for the development of innovative and sustainable chronic care models. Keywords: heart failure; telemedicine; telemonitoring; Family and Community Nurse; continuity of care; chronic disease management; community healthcare.| File | Dimensione | Formato | |
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https://hdl.handle.net/20.500.12075/28925