The document provides an overview of the healthcare system in the Tuscan region of Italy. It discusses the national health service and how the Tuscan region organizes its local health authorities. It then focuses on Tuscan regional planning for chronic diseases, explaining how it uses the Chronic Care Model (CCM) within primary healthcare centers. The CCM aims to better manage chronic conditions through a proactive approach led by general practitioners, nurses and other professionals. Initial results show the CCM has reduced costs and hospital admissions while improving health outcomes and decreasing health inequalities. The presentation concludes by outlining the expansion of primary healthcare centers that implement the CCM across Tuscany.

1. Lodz – Polonia, 26.02.13
OVERALL PRESENTATION OF THE
HEALTHCARE SYSTEM IN THE REGION
OF TUSCANY
Piero Salvadori
RETOS
Tuscany Region Directorate-General
Services to people in the territory

2. Index of the presentation
1. National health service
2. Tuscan health service
3. Tuscan Regional Planning for chronic diseases
4. The Chronic Care Model: how it works
5. The results of chronic care model (CCM)
6. The primary health care centres (PHC X CCM)

3. Index of the presentation
1. National health service
2. Tuscan health service
3. Tuscan Regional Planning for chronic diseases
4. The Chronic Care Model: how it works
5. The results of chronic care model (CCM)
6. The primary health care centres (PHC X CCM)

4. Seventh Framework Programme
Regions of Knowledge Health
Grant agreement no: 266262
National Health Service born in 1978
Before there were insurances for categories of citizens
(workers, salesman, professionals….).
Some citizens were without health care.
p.salvadori@usl11.toscana.it 4

5. Seventh Framework Programme
Regions of Knowledge Health
Grant agreement no: 266262
LOCAL HEALTH AUTHORITIES
From 1978 to 1992 in Italy there
were 659 Local Health
Authorities ( 40 in Tuscany
Region)
Since 1992 to today we have 228
local health authorities ( 12 in
Tuscany Region)
p.salvadori@usl11.toscana.it 5

6. Seventh Framework Programme
Regions of Knowledge Health
Grant agreement no: 266262
1992 2 ND
REFORM
Local Health Authorities become
similar to private company headed
by a General Director
the budget of LHA must be in
balance. If it isn’t the Director
General may be dismissed, and with
him the health director and
administrative director
p.salvadori@usl11.toscana.it 6

7. Seventh Framework Programme
Regions of Knowledge Health
Grant agreement no: 266262
In 2001 is modified our constitution :
So, the Italian Regions can
independently organize health within
its territory. There is the possibility
of having 21 different health systems
p.salvadori@usl11.toscana.it 7

8. Seventh Framework Programme
Italy is divided in 21 Regions Regions of Knowledge Health
Grant agreement no: 266262
We are here
p.salvadori@usl11.toscana.it 8

9. REGIONS Number of Local Health AuthoritiesSeventh Framework Programme
Regions of Knowledge Health
Grant agreement no: 266262
LHA (Company) Hospital Companies
ante 502/92 31/12/1995 01/05/2002 31/12/1995 01/05/2002
Piemonte 63 22 22 7 7
Val d Aosta 1 1 1 - -
Lombardia 84 44 15 16 29
Bolzano 4 4 4 - -
Trento 11 1 1 - -
Veneto 36 22 21 2 2
Friuli Venezia Giulia 12 6 6 3 3
Liguria 20 5 5 3 3
Emilia Romagna 41 13 13 5 5
Toscana 40 12 12 4 4
Umbria 12 5 4 2 2
Marche 24 13 13 3 4
Lazio 51 12 12 3 3
Abruzzo 15 6 6 - -
Molise 7 4 4 - -
Campania 61 13 13 7 8
Puglia 55 12 12 4 6
Basilicata 7 5 5 1 1
Calabria 31 11 11 4 4
Sicilia 62 9 9 16 17
Sardegna 22 8 8 1 1
TOTAL 659 228 197 81 99
p.salvadori@usl11.toscana.it 9

10. Seventh Framework Programme
Regions of Knowledge Health
Grant agreement no: 266262
FINANCING
Citizens pay taxes Central government
Regions
Local Health Authorities
p.salvadori@usl11.toscana.it 10

11. Seventh Framework Programme
Regions of Knowledge Health
Grant agreement no: 266262
Health Organization in Italy
Private
25%
Public
There aren’t any insurances 75%
p.salvadori@usl11.toscana.it 11

12. Seventh Framework Programme
DISTRIBUTION OF ECONOMIC RESOURCES Regions of Knowledge Health
Grant agreement no: 266262
Primary care
p.salvadori@usl11.toscana.it 12

13. Index of the presentation
1. National health system
2. Tuscan health service
3. Tuscan Regional Planning for chronic diseases
4. The Chronic Care Model: how it works
5. The results of chronic care model (CCM)
6. The primary health care centres (PHC X CCM)

14. Seventh Framework Programme
Regions of Knowledge Health
Grant agreement no: 266262
•The Tuscan Healthcare System: some
data
•3,7 millions inhabitants
• 17 Public Health Authorities:
12 Local Health Authorities and 5 Teaching
Hospitals
organized in three Network “Area Vasta”:
• North West Area Vasta: 2 T.H. and 5 L.H.A.
• Center Area Vasta: 2 T.H. and 4 L.H.A.
• South East Area Vasta: 1 T.H. and 3 L.H.A.
• 2.940 GPs (1200 patients on the average) [2009]

15. Seventh Framework Programme
In Tuscany Region: Regions of Knowledge Health
Grant agreement no: 266262
•Free of charge: hospital admission and care, home
care, prevention assistance.
•With ticket payment:
• Specialist visits and exams
• drugs
p.salvadori@usl11.toscana.it 15

16. Index of the presentation
1. National health service
2. Tuscan health service
3. Tuscan Regional Planning for chronic diseases
4. The Chronic Care Model: how it works
5. The results of chronic care model (CCM)
6. The primary health care centres (PHC X CCM)

17. Seventh Framework Programme
Regions of Knowledge Health
Grant agreement no: 266262
Tuscan regional planning
Face chronic
epidemic
How ? With chronic care model
Where ? Into Primary Healthcare
centres in territory, Health
Clinic (Case della Salute)
With whom ? General Practitioners,
Nurses, Administrative
Personnel, Social Workers

18. The Territory from Seventh Framework Programme
GPs’
Regions of Knowledge Health
the region to the Grant agreement no: 266262
Association
Primary Health care
Centre
Local
Region Neywork «Area Health Health
Vasta» Authority Care Area
LHA
Primary
Healthcare
Centre
«Casa della
Salute»

20. Index of the presentation
1. National health service
2. Tuscan health service
3. Tuscan Regional Planning for chronic diseases
4. The Chronic Care Model: how it works
5. The results of chronic care model (CCM)
6. The primary health care centres (PHC X CCM)

21. Seventh Framework Programme
Regions of Knowledge Health
Grant agreement no: 266262
HOW IT WORKS 1/2
 Five diseases: diabetes, stroke/TIA, heart failure,
hypertension and COPD. We are seriously considering to
extend the CCM to the dementia
 General Practitioners (GPs) select patients and citizens
at high risk. They make their risk or pathology registers
 Nurses follow these people through predefined
protocols by examination and counselling. For example,
for diabetes, glycated haemoglobin, diet, weight control,
self-control, physical activity etc.

22. Seventh Framework Programme
Regions of Knowledge Health
Grant agreement no: 266262
HOW IT WORKS 2/2
 If the patient goes outside protocol predefined limits
GP’s visit are scheduled
 Obviously there are other professionals such as
physiotherapist, dietician, etc. ...
 Hospital physician sees patients only if decompensated

23. Chronic Care Model (CCM) – Key Notes Seventh Framework Programme
Regions of Knowledge Health
Grant agreement no: 266262
GP select their patients nurses are in line with
with the five most GP’ computers. They
common and important see the GP disease
chronic diseases from register, call these
their computer records patients in their nurse
of pathology offices or follow them
by homecare. They do
to patients tests, visit,
screening, counseling,
etc. ... by predefined
protocols
Patients who have
disease indicators out
of the protocol back to
visit from their own Patients followed with
GP, because they are CCM avoid
out of balance hospitalization and
relapses of chronic
diseases, use less drugs
and diagnostics

24. Where Tuscany wants to invest? Seventh Framework Programme
Regions of Knowledge Health
Grant agreement no: 266262
From traditional healthcare to proactive healthcare
Traditional healthcare: Proactive healthcare:
The healthcare system acts only The patient’s needs are taken into
when the chronic patient worsens account before the disease
becoming acute. worsening and possibly before
disease onset, getting better health
conditions for the population,
addressing equity issue too.
Chronic diseases are not well
treated and prevention as well
as risk factors are not taken
into account. Health inequities The healthcare system is able
are not taken into account to manage chronic diseases
and to be effective in facing
the acute diseases onset.

25. Seventh Framework Programme
Regions of Knowledge Health
WHICH MODEL TO DRIVE THE CHANGE: Grant agreement no: 266262
THE EXPANDED CHRONIC CARE MODEL (CCM)
Expanded Chronic Care Model:
 main strategy of the Regional Health
Plan
 new delivery System design focused on
multi-professional care team
 new role of nurses in self management
support;
 decision support through shared clinical
pathways;
 investment on integrated information
system
 community resources exploitation
 Focus on prevention and health
determinants (community oriented
primary care)

26. Seventh Framework Programme
concepts of proactive medicine Regions of Knowledge Health
Grant agreement no: 266262
Health problem When What
Infectious diseases First 60 years of Vaccinations
the '900
Cancer The last 40 years Screening
of the '900
Chronic
End 900 - Chronic
epidemic
beginning of care model
this century
26

27. Seventh Framework Programme
Regions of Knowledge Health
Grant agreement no: 266262
GPS AND OTHER HEALTH PROFESSIONALS OPERATORS
(NURSES, MEDICAL ASSISTANT …) ORGANIZED IN PRACTICE
(6-15 GPS) TO CARE FOR CHRONIC PATIENTS WITH A
PROACTIVE APPROACH (CHRONIC CARE MODEL)
11 LHAs
• 56 practice
Pilot phase
• 497 GPs
June 2010
•112 Nurses
• 618.969 Patients
Other groups are expected to be involved
Extention phase • 31 practice
March 2011 • 301 GPs
• 62 Nurses
• 337.213 Patients
27

28. Index of the presentation
1. National health service
2. Tuscan health service
3. Tuscan Regional Planning for chronic diseases
4. The Chronic Care Model: how it works
5. The results of chronic care model (CCM)
6. The primary health care centres (PHC X CCM)

29. Seventh Framework Programme
Per-capita spending of diabetic visit Regions of Knowledge Health
Grant agreement no: 266262
8,0 2010
7,0
6,0
5,0
4,0
3,0
2,0
2009 2010
CCM NO - CCM
Francesconi P., Tuscan Health Agency

30. Impact on inequalities Seventh Framework Programme
Regions of Knowledge Health
Grant agreement no: 266262
HbA1c
100
90
80
Deprived
%
70
Not deprived
60
50
40
2009 2010
Lipids
100
90
80
70
Deprived
%
60
Not deprived
50
40
30
20
2009 2010
Francesconi P., Tuscan Health Agency

31. Seventh Framework Programme
Regions of Knowledge Health
Grant agreement no: 266262
Inpatients hospital admission rate
31

32. Seventh Framework Programme
Regions of Knowledge Health
SOME RESULTS ½ Grant agreement no: 266262
STRENGTHS
 People are very happy for this model. They really like it
 reduce hospital admissions for the five diseases and
their costs
 reduce hospital visits for these diseases and waiting lists
 reduce the gap between rich and poor people in using
health services

33. Seventh Framework Programme
Regions of Knowledge Health
SOME RESULTS 2/2 Grant agreement no: 266262
WEAKNESSES
 The model is running almost half of Tuscan Population,
but we will improve it
 The number of visits in our Primary Health Centres is
increasing, of course
 We need a robust ICT net (information system, tele-
health, broadband…) to continue to implement this
model. Now we have only partially.

34. Index of the presentation
1. National health service
2. Tuscan health service
3. Tuscan Regional Planning for chronic diseases
4. The Chronic Care Model: how it works
5. The results of chronic care model (CCM)
6. The primary health care centres (PHC X CCM)

35. Seventh Framework Programme
Primary Healthcare Centres Regions of Knowledge Health
Grant agreement no: 266262
Health clinics
Health Houses
Case della salute
This is a building where work together
• GPs
• nurses,
• administrative personnal,
• social workers,
• social health personnel,
• doctor specialists
• etc.,
It is always open h24, 7/7

36. Massa
Carrara Casa della Salute –Seventh Framework Programme
2004 Health
Regions of Knowledge
Grant agreement no: 266262
Florence
Pisa
Arezzo
Castiglion Fiorentino
Livorno
Siena
Grosseto
piero.salvadori@regione.t 36
oscana.it

37. Massa
Carrara Case della Salute –Seventh Framework Programme
2007 Health
Regions of Knowledge
Grant agreement no: 266262
Quarrata
Florence
Terricciola
Pisa Empoli
Arezzo
Castiglion Fiorentino
Livorno
Siena
Grosseto
piero.salvadori@regione.t 37
oscana.it

38. Massa
Carrara Case della Salute - Seventh Framework Programme
2010
Regions of Knowledge Health
Grant agreement no: 266262
Marlia Agliana Colline Medicee
Piazza al Serchio Lamporecchio (*) Val di Bisenzio
Montemurlo
Viareggio Florence
Quarrata Campi Bisenzio
Pisa
Terricciola Scandicci
Empoli Arezzo
Castiglion Fiorentino
Livorno
Siena
Grosseto
piero.salvadori@regione.t 38
oscana.it

39. Seventh Framework Programme
Regions of Knowledge Health
Grant agreement no: 266262
Year Are Will In TOTAL
working open project
2012 20 20
2013 13 33
2014 17 50
piero.salvadori@regione.t 39
oscana.it

40. Seventh Framework Programme
Regions of Knowledge Health
Grant agreement no: 266262
piero.salvadori@regione.toscana.it 40