[Diagnostic therapeutic care paths including rehabilitation or ‘discharge’ rehabilitation?]

Due to epidemiological and social changes related to the increase in the average life expectancy, hospital users are characterized by elderly chronic and comorbid patients who require recurrent hospitalizations often with disability outcomes. In this framework, an innovative clinical and management hospitalization model is the adequate answer to systematically promote the patient independence. Main features are interdisciplinary and integrated care pathways facing both disease and disability biologically and functionally diagnosed by ICD and ICF. The definition, personalization of pathways/protocols and outcome evaluation represent the foundations of this new model for patient care.The digitalization of hospital clinical data and medical knowledge make the model feasible and fitting the recent WHO guideline: recommendations on digital interventions for health system strengthening.