Beyond the Hospital

Facing cancer means embarking on a journey that goes beyond diagnosis and treatment, affecting many aspects of the lives of both patients and their families.

For this reason, the Fondazione Poliambulanza Cancer Centre promotes a comprehensive, multidisciplinary model of care designed to support patients throughout every stage of their care pathway: from prevention and early diagnosis to treatment, from rehabilitation to follow-up, as well as the management of any vulnerabilities and care needs that may arise over time.

A Care Pathway Built Around the Patient

Each patient may have different needs, related not only to the disease itself, but also to their overall health, level of independence, and family, work, and social circumstances.

The aim is to identify these needs at an early stage and, when necessary, facilitate coordinated intervention by the appropriate professionals and services, ensuring continuity and appropriateness of care.

Alongside specialist oncology care, the care pathway may therefore include:

• psychological and psycho-oncological support, to help patients and their families cope with the emotional impact of cancer;
• social support, to provide guidance on available services and address issues related to vulnerability, family circumstances, care needs, or employment;
• nutritional and rehabilitation support, to preserve or restore independence, functional capacity, and quality of life as much as possible;
• caregiver involvement and support, recognizing the essential role of family members and others involved in the patient’s care;
• palliative care and symptom management, when appropriate, integrated early into the care pathway and not limited solely to the final stages of the disease;
• prevention and health promotion programs, aimed both at the general population and at people who have completed cancer treatment.

After Treatment: Continuing to Take Care of Your Health

The cancer care pathway does not necessarily end when treatment is completed.

Particular attention is also given to the post-treatment phase through follow-up and survivorship care, with the aim of supporting patients in managing any long-term effects of treatment and promoting healthy lifestyles, physical activity, a balanced diet, preventive care, and participation in recommended screening programs.

Continuity of Care Between Hospital and Community Services

A key aspect of comprehensive patient care is ensuring that the care pathway continues beyond the hospital setting.

When required by the patient’s condition, coordination is established with the General Practitioner (GP) and local healthcare, health and social care, and social services to facilitate access to home care, rehabilitation pathways, palliative care, or other forms of support.

For patients with more complex needs, discharge planning and coordination among the different healthcare professionals help ensure a safe and seamless transition from hospital to home or to other care settings.

Which Care Pathways Can Be Activated?

Depending on the patient’s specific needs, the Protected Discharge Service can facilitate coordination with a range of community-based services and care facilities, including:
 

• home care and healthcare services;
• rehabilitation or intermediate care pathways;
• Community Hospitals and other facilities providing post-acute care;
• Residential Care Facilities and other residential care options;
• hospices and home-based palliative care services;
• social services and other community-based organizations supporting patients and their families.

Particular attention is given to older people and people with disabilities, patients with complex or oncological conditions, and, more generally, individuals experiencing health-related or social vulnerability.

A Network of Healthcare Professionals and Services

The Cancer Centre model is based on collaboration among different healthcare professionals and on the ability to connect hospital care, community-based services, patients, and their families.

The aim is to provide a care pathway in which patients are not left to navigate the different services on their own, but are supported throughout the various stages of their illness, identifying at each stage the most appropriate response to their clinical, care, psychological, and social needs.

Treating cancer also means caring for the person, their quality of life, and the continuity of their care pathway.

Discharge from hospital is an important stage in the care pathway. For some patients, particularly those with clinical vulnerabilities, reduced independence, or complex social and care needs, returning home or transitioning to another care setting requires particular attention and appropriate coordination of services.

Fondazione Poliambulanza’s Protected Discharge Service aims to support these patients in the transition from hospital to community-based care, promoting continuity of care and working with the hospital team to identify the most appropriate care pathway.

The service may become involved during hospitalization when healthcare, care-related, or social needs arise that require careful discharge planning. The assessment takes into account the patient’s overall condition, level of independence, care needs, family and social circumstances, and the availability of caregivers.

When necessary, patients and their families are actively involved in planning the care pathway following discharge.

Connecting Hospital and Community Care

Protected discharge is based on collaboration between hospital professionals and community-based services.

Depending on the patient’s needs, the General Practitioner (GP), local healthcare and health and social care services, social services, and the facilities responsible for providing ongoing care may all be involved in the process.

Coordination with the Community Operations Centre (Centrale Operativa Territoriale – COT) of the relevant local ASST also helps facilitate coordination between hospital and community care and supports transitions across different care settings.

The aim is to ensure continuity of care that is as safe, appropriate, and personalized as possible, so that patients and their families are not left to manage alone what can often be a complex period following hospital discharge.

The patient, their needs, and continuity of care always remain at the heart of the care pathway.

To contact the service:

call +39 030 3515291, Monday to Friday, from 9:00 a.m. to 3:00 p.m.