Manage Integrated Social Health for a Sustainable Health Home Care Model

Covid 19 has increased the need for a service chain integration by imposing transformation processes of healthcare organizations, challenged with the complexity of the demand for health and the evolution of the services chain (both public and accredited private). This process increases the needs of integration between the parts of the sanitary system as the socio-health district. Alongside the need for integration, a need for "navigability" is developing between operators and users, especially among chronic population targets with greater socio-health complexity. All this determines a growing need for connection which sees in transition care models a new form of work specialization requiring new role profiles, ability to relate and dialogue between operators, operational management tools relating to the service chain of territorial services, specific information collection and management systems. In this context the change is activated by Knowledge management. KM assumes the task of stimulate and develop, with adequate training, incentive and communication tools, the ability to learn within the organization, generating a culture open to continuous comparison, to measurement and discussion of the results (Havens & Knapp, 2005). Processes of change are based on the exchange of experiences, on the dissemination of results and knowledge between internal/external administrations to the system, which often activate, second participatory logics, intense interactions creating networks, partnerships, and networks (from regulatory to knowledge management). The paper analyses the relationships between the actors of the regional governance system with the aim of observing the different models of regional governance in national context especially comparing home care systems and defines possible processes of change with the introduction of ICT in home care and assistance processes. Furthermore, the study observes how the integrated socio-health care of chronicity management through ICT tools is to implement an effective, integrated, and sustainable home care model for the chronic user, hospitalized for one or more high-impact chronic diseases (e.g. compensation, diabetes, COPD).