Clinical Nursing Sciences 3

· Contest analysis and Community nursing care models
a) The network of social-health services: continuity between care settings, protected discharge project, health care services, primary care, intermediate care, home care, hospice, integrated care models, chronic care model, CreG (CronicRelated Group) , regional networks, the relationship between nurses and patient's relatives in hospital and at home, the meaning of continuity of care, the concept of hospital discharge process and feasibility / acceptability at home.
b) Reference legislation:
- Law 833/1978 "Establishment of the National Health System"
- Legislative Decree 502/1992 and Law n. 724 of 23rd December 1994
- The Regional Health System: regional legislation (Operating rules)
- European Directives on continuity care between hospital, community and home care
- Law 328/2000 Realization of the integrated system of interventions and social services.
- National Health Plan and Essential Levels of Care (LEA)
- Law n. 38 of 15th March 2010, Provisions to ensure access to palliative care and pain therapy.

c) Actors and recipients of nursing care:
- Family nurse, case manager
- Family, person, group, community
- The multi-professional team
- The role of the caregiver in different care settings







· Preventive nursing care
Methods and tools for nursing care:
Therapeutic education for individuals, families and particular groups, with interventions on the environment, nutrition, relationships, adherence to therapy, to guarantee a good quality of life for people with chronic degenerative diseases: AIDS, tuberculosis , oncological and/or hematological diseases, aged people, with cognitive problems
Use of IADL (Instrumental Activities of Daily Living) assessment scales in the aged people at intra and extra-hospital care services
Diagnostic and therapeutic paths at home
Integrated home documentation

· Nursing care for people:
In the end of life and accompaniment to death; support to family members in the choices at the end of life and during the mourning phases
In oncological and non-oncological palliative care and pain treatment
In a condition of chronic and chronic degenerative conditions (eg. aged people, disabled, severe psycho-physical frailties
In people with oncological and / or hematological pathology (eg. immunodepressed people, oral anticoagulants therapy)

Therapeutic education project for people in chronic-degenerative conditions, family, caregivers, community in extra-hospital contexts, with particular attention to ethical implications.
Exercise (through role play or video projection) for the development of communication skills to expand palliative and end of life care

· Contest analysis and Community nursing care models
a) The network of social-health services: continuity between care settings, protected discharge project, health care services, primary care, intermediate care, home care, hospice, integrated care models, chronic care model, CreG (CronicRelated Group) , regional networks, the relationship between nurses and patient's relatives in hospital and at home, the meaning of continuity of care, the concept of hospital discharge process and feasibility / acceptability at home.
b) Reference legislation:
- Law 833/1978 "Establishment of the National Health System"
- Legislative Decree 502/1992 and Law n. 724 of 23rd December 1994
- The Regional Health System: regional legislation (Operating rules)
- European Directives on continuity care between hospital, community and home care
- Law 328/2000 Realization of the integrated system of interventions and social services.
- National Health Plan and Essential Levels of Care (LEA)
- Law n. 38 of 15th March 2010, Provisions to ensure access to palliative care and pain therapy.

c) Actors and recipients of nursing care:
- Family nurse, case manager
- Family, person, group, community
- The multi-professional team
- The role of the caregiver in different care settings







· Preventive nursing care
Methods and tools for nursing care:
Therapeutic education for individuals, families and particular groups, with interventions on the environment, nutrition, relationships, adherence to therapy, to guarantee a good quality of life for people with chronic degenerative diseases: AIDS, tuberculosis , oncological and/or hematological diseases, aged people, with cognitive problems
Use of IADL (Instrumental Activities of Daily Living) assessment scales in the aged people at intra and extra-hospital care services
Diagnostic and therapeutic paths at home
Integrated home documentation

· Nursing care for people:
In the end of life and accompaniment to death; support to family members in the choices at the end of life and during the mourning phases
In oncological and non-oncological palliative care and pain treatment
In a condition of chronic and chronic degenerative conditions (eg. aged people, disabled, severe psycho-physical frailties
In people with oncological and / or hematological pathology (eg. immunodepressed people, oral anticoagulants therapy)

Therapeutic education project for people in chronic-degenerative conditions, family, caregivers, community in extra-hospital contexts, with particular attention to ethical implications.
Exercise (through role play or video projection) for the development of communication skills to expand palliative and end of life care

· Contest analysis and Community nursing care models
a) The network of social-health services: continuity between care settings, protected discharge project, health care services, primary care, intermediate care, home care, hospice, integrated care models, chronic care model, CreG (CronicRelated Group) , regional networks, the relationship between nurses and patient's relatives in hospital and at home, the meaning of continuity of care, the concept of hospital discharge process and feasibility / acceptability at home.
b) Reference legislation:
- Law 833/1978 "Establishment of the National Health System"
- Legislative Decree 502/1992 and Law n. 724 of 23rd December 1994
- The Regional Health System: regional legislation (Operating rules)
- European Directives on continuity care between hospital, community and home care
- Law 328/2000 Realization of the integrated system of interventions and social services.
- National Health Plan and Essential Levels of Care (LEA)
- Law n. 38 of 15th March 2010, Provisions to ensure access to palliative care and pain therapy.

c) Actors and recipients of nursing care:
- Family nurse, case manager
- Family, person, group, community
- The multi-professional team
- The role of the caregiver in different care settings







· Preventive nursing care
Methods and tools for nursing care:
Therapeutic education for individuals, families and particular groups, with interventions on the environment, nutrition, relationships, adherence to therapy, to guarantee a good quality of life for people with chronic degenerative diseases: AIDS, tuberculosis , oncological and/or hematological diseases, aged people, with cognitive problems
Use of IADL (Instrumental Activities of Daily Living) assessment scales in the aged people at intra and extra-hospital care services
Diagnostic and therapeutic paths at home
Integrated home documentation

· Nursing care for people:
In the end of life and accompaniment to death; support to family members in the choices at the end of life and during the mourning phases
In oncological and non-oncological palliative care and pain treatment
In a condition of chronic and chronic degenerative conditions (eg. aged people, disabled, severe psycho-physical frailties
In people with oncological and / or hematological pathology (eg. immunodepressed people, oral anticoagulants therapy)

Therapeutic education project for people in chronic-degenerative conditions, family, caregivers, community in extra-hospital contexts, with particular attention to ethical implications.
Exercise (through role play or video projection) for the development of communication skills to expand palliative and end of life care

· Contest analysis and Community nursing care models
a) The network of social-health services: continuity between care settings, protected discharge project, health care services, primary care, intermediate care, home care, hospice, integrated care models, chronic care model, CreG (CronicRelated Group) , regional networks, the relationship between nurses and patient's relatives in hospital and at home, the meaning of continuity of care, the concept of hospital discharge process and feasibility / acceptability at home.
b) Reference legislation:
- Law 833/1978 "Establishment of the National Health System"
- Legislative Decree 502/1992 and Law n. 724 of 23rd December 1994
- The Regional Health System: regional legislation (Operating rules)
- European Directives on continuity care between hospital, community and home care
- Law 328/2000 Realization of the integrated system of interventions and social services.
- National Health Plan and Essential Levels of Care (LEA)
- Law n. 38 of 15th March 2010, Provisions to ensure access to palliative care and pain therapy.

c) Actors and recipients of nursing care:
- Family nurse, case manager
- Family, person, group, community
- The multi-professional team
- The role of the caregiver in different care settings







· Preventive nursing care
Methods and tools for nursing care:
Therapeutic education for individuals, families and particular groups, with interventions on the environment, nutrition, relationships, adherence to therapy, to guarantee a good quality of life for people with chronic degenerative diseases: AIDS, tuberculosis , oncological and/or hematological diseases, aged people, with cognitive problems
Use of IADL (Instrumental Activities of Daily Living) assessment scales in the aged people at intra and extra-hospital care services
Diagnostic and therapeutic paths at home
Integrated home documentation

· Nursing care for people:
In the end of life and accompaniment to death; support to family members in the choices at the end of life and during the mourning phases
In oncological and non-oncological palliative care and pain treatment
In a condition of chronic and chronic degenerative conditions (eg. aged people, disabled, severe psycho-physical frailties
In people with oncological and / or hematological pathology (eg. immunodepressed people, oral anticoagulants therapy)

Therapeutic education project for people in chronic-degenerative conditions, family, caregivers, community in extra-hospital contexts, with particular attention to ethical implications.
Exercise (through role play or video projection) for the development of communication skills to expand palliative and end of life care

· Contest analysis and Community nursing care models
a) The network of social-health services: continuity between care settings, protected discharge project, health care services, primary care, intermediate care, home care, hospice, integrated care models, chronic care model, CreG (CronicRelated Group) , regional networks, the relationship between nurses and patient's relatives in hospital and at home, the meaning of continuity of care, the concept of hospital discharge process and feasibility / acceptability at home.
b) Reference legislation:
- Law 833/1978 "Establishment of the National Health System"
- Legislative Decree 502/1992 and Law n. 724 of 23rd December 1994
- The Regional Health System: regional legislation (Operating rules)
- European Directives on continuity care between hospital, community and home care
- Law 328/2000 Realization of the integrated system of interventions and social services.
- National Health Plan and Essential Levels of Care (LEA)
- Law n. 38 of 15th March 2010, Provisions to ensure access to palliative care and pain therapy.

c) Actors and recipients of nursing care:
- Family nurse, case manager
- Family, person, group, community
- The multi-professional team
- The role of the caregiver in different care settings







· Preventive nursing care
Methods and tools for nursing care:
Therapeutic education for individuals, families and particular groups, with interventions on the environment, nutrition, relationships, adherence to therapy, to guarantee a good quality of life for people with chronic degenerative diseases: AIDS, tuberculosis , oncological and/or hematological diseases, aged people, with cognitive problems
Use of IADL (Instrumental Activities of Daily Living) assessment scales in the aged people at intra and extra-hospital care services
Diagnostic and therapeutic paths at home
Integrated home documentation

· Nursing care for people:
In the end of life and accompaniment to death; support to family members in the choices at the end of life and during the mourning phases
In oncological and non-oncological palliative care and pain treatment
In a condition of chronic and chronic degenerative conditions (eg. aged people, disabled, severe psycho-physical frailties
In people with oncological and / or hematological pathology (eg. immunodepressed people, oral anticoagulants therapy)

Therapeutic education project for people in chronic-degenerative conditions, family, caregivers, community in extra-hospital contexts, with particular attention to ethical implications.
Exercise (through role play or video projection) for the development of communication skills to expand palliative and end of life care

· Contest analysis and Community nursing care models
a) The network of social-health services: continuity between care settings, protected discharge project, health care services, primary care, intermediate care, home care, hospice, integrated care models, chronic care model, CreG (CronicRelated Group) , regional networks, the relationship between nurses and patient's relatives in hospital and at home, the meaning of continuity of care, the concept of hospital discharge process and feasibility / acceptability at home.
b) Reference legislation:
- Law 833/1978 "Establishment of the National Health System"
- Legislative Decree 502/1992 and Law n. 724 of 23rd December 1994
- The Regional Health System: regional legislation (Operating rules)
- European Directives on continuity care between hospital, community and home care
- Law 328/2000 Realization of the integrated system of interventions and social services.
- National Health Plan and Essential Levels of Care (LEA)
- Law n. 38 of 15th March 2010, Provisions to ensure access to palliative care and pain therapy.

c) Actors and recipients of nursing care:
- Family nurse, case manager
- Family, person, group, community
- The multi-professional team
- The role of the caregiver in different care settings







· Preventive nursing care
Methods and tools for nursing care:
Therapeutic education for individuals, families and particular groups, with interventions on the environment, nutrition, relationships, adherence to therapy, to guarantee a good quality of life for people with chronic degenerative diseases: AIDS, tuberculosis , oncological and/or hematological diseases, aged people, with cognitive problems
Use of IADL (Instrumental Activities of Daily Living) assessment scales in the aged people at intra and extra-hospital care services
Diagnostic and therapeutic paths at home
Integrated home documentation

· Nursing care for people:
In the end of life and accompaniment to death; support to family members in the choices at the end of life and during the mourning phases
In oncological and non-oncological palliative care and pain treatment
In a condition of chronic and chronic degenerative conditions (eg. aged people, disabled, severe psycho-physical frailties
In people with oncological and / or hematological pathology (eg. immunodepressed people, oral anticoagulants therapy)

Therapeutic education project for people in chronic-degenerative conditions, family, caregivers, community in extra-hospital contexts, with particular attention to ethical implications.
Exercise (through role play or video projection) for the development of communication skills to expand palliative and end of life care

· Contest analysis and Community nursing care models
a) The network of social-health services: continuity between care settings, protected discharge project, health care services, primary care, intermediate care, home care, hospice, integrated care models, chronic care model, CreG (CronicRelated Group) , regional networks, the relationship between nurses and patient's relatives in hospital and at home, the meaning of continuity of care, the concept of hospital discharge process and feasibility / acceptability at home.
b) Reference legislation:
- Law 833/1978 "Establishment of the National Health System"
- Legislative Decree 502/1992 and Law n. 724 of 23rd December 1994
- The Regional Health System: regional legislation (Operating rules)
- European Directives on continuity care between hospital, community and home care
- Law 328/2000 Realization of the integrated system of interventions and social services.
- National Health Plan and Essential Levels of Care (LEA)
- Law n. 38 of 15th March 2010, Provisions to ensure access to palliative care and pain therapy.

c) Actors and recipients of nursing care:
- Family nurse, case manager
- Family, person, group, community
- The multi-professional team
- The role of the caregiver in different care settings







· Preventive nursing care
Methods and tools for nursing care:
Therapeutic education for individuals, families and particular groups, with interventions on the environment, nutrition, relationships, adherence to therapy, to guarantee a good quality of life for people with chronic degenerative diseases: AIDS, tuberculosis , oncological and/or hematological diseases, aged people, with cognitive problems
Use of IADL (Instrumental Activities of Daily Living) assessment scales in the aged people at intra and extra-hospital care services
Diagnostic and therapeutic paths at home
Integrated home documentation

· Nursing care for people:
In the end of life and accompaniment to death; support to family members in the choices at the end of life and during the mourning phases
In oncological and non-oncological palliative care and pain treatment
In a condition of chronic and chronic degenerative conditions (eg. aged people, disabled, severe psycho-physical frailties
In people with oncological and / or hematological pathology (eg. immunodepressed people, oral anticoagulants therapy)

Therapeutic education project for people in chronic-degenerative conditions, family, caregivers, community in extra-hospital contexts, with particular attention to ethical implications.
Exercise (through role play or video projection) for the development of communication skills to expand palliative and end of life care

· Contest analysis and Community nursing care models
a) The network of social-health services: continuity between care settings, protected discharge project, health care services, primary care, intermediate care, home care, hospice, integrated care models, chronic care model, CreG (CronicRelated Group) , regional networks, the relationship between nurses and patient's relatives in hospital and at home, the meaning of continuity of care, the concept of hospital discharge process and feasibility / acceptability at home.
b) Reference legislation:
- Law 833/1978 "Establishment of the National Health System"
- Legislative Decree 502/1992 and Law n. 724 of 23rd December 1994
- The Regional Health System: regional legislation (Operating rules)
- European Directives on continuity care between hospital, community and home care
- Law 328/2000 Realization of the integrated system of interventions and social services.
- National Health Plan and Essential Levels of Care (LEA)
- Law n. 38 of 15th March 2010, Provisions to ensure access to palliative care and pain therapy.

c) Actors and recipients of nursing care:
- Family nurse, case manager
- Family, person, group, community
- The multi-professional team
- The role of the caregiver in different care settings







· Preventive nursing care
Methods and tools for nursing care:
Therapeutic education for individuals, families and particular groups, with interventions on the environment, nutrition, relationships, adherence to therapy, to guarantee a good quality of life for people with chronic degenerative diseases: AIDS, tuberculosis , oncological and/or hematological diseases, aged people, with cognitive problems
Use of IADL (Instrumental Activities of Daily Living) assessment scales in the aged people at intra and extra-hospital care services
Diagnostic and therapeutic paths at home
Integrated home documentation

· Nursing care for people:
In the end of life and accompaniment to death; support to family members in the choices at the end of life and during the mourning phases
In oncological and non-oncological palliative care and pain treatment
In a condition of chronic and chronic degenerative conditions (eg. aged people, disabled, severe psycho-physical frailties
In people with oncological and / or hematological pathology (eg. immunodepressed people, oral anticoagulants therapy)

Therapeutic education project for people in chronic-degenerative conditions, family, caregivers, community in extra-hospital contexts, with particular attention to ethical implications.
Exercise (through role play or video projection) for the development of communication skills to expand palliative and end of life care

· Contest analysis and Community nursing care models
a) The network of social-health services: continuity between care settings, protected discharge project, health care services, primary care, intermediate care, home care, hospice, integrated care models, chronic care model, CreG (CronicRelated Group) , regional networks, the relationship between nurses and patient's relatives in hospital and at home, the meaning of continuity of care, the concept of hospital discharge process and feasibility / acceptability at home.
b) Reference legislation:
- Law 833/1978 "Establishment of the National Health System"
- Legislative Decree 502/1992 and Law n. 724 of 23rd December 1994
- The Regional Health System: regional legislation (Operating rules)
- European Directives on continuity care between hospital, community and home care
- Law 328/2000 Realization of the integrated system of interventions and social services.
- National Health Plan and Essential Levels of Care (LEA)
- Law n. 38 of 15th March 2010, Provisions to ensure access to palliative care and pain therapy.

c) Actors and recipients of nursing care:
- Family nurse, case manager
- Family, person, group, community
- The multi-professional team
- The role of the caregiver in different care settings







· Preventive nursing care
Methods and tools for nursing care:
Therapeutic education for individuals, families and particular groups, with interventions on the environment, nutrition, relationships, adherence to therapy, to guarantee a good quality of life for people with chronic degenerative diseases: AIDS, tuberculosis , oncological and/or hematological diseases, aged people, with cognitive problems
Use of IADL (Instrumental Activities of Daily Living) assessment scales in the aged people at intra and extra-hospital care services
Diagnostic and therapeutic paths at home
Integrated home documentation

· Nursing care for people:
In the end of life and accompaniment to death; support to family members in the choices at the end of life and during the mourning phases
In oncological and non-oncological palliative care and pain treatment
In a condition of chronic and chronic degenerative conditions (eg. aged people, disabled, severe psycho-physical frailties
In people with oncological and / or hematological pathology (eg. immunodepressed people, oral anticoagulants therapy)

Therapeutic education project for people in chronic-degenerative conditions, family, caregivers, community in extra-hospital contexts, with particular attention to ethical implications.
Exercise (through role play or video projection) for the development of communication skills to expand palliative and end of life care

a) The network of social-health services: continuity between care settings, protected discharge project, health care services, primary care, intermediate care, home care, hospice, integrated care models, chronic care model, CreG (CronicRelated Group) , regional networks, the relationship between nurses and patient's relatives in hospital and at home, the meaning of continuity of care, the concept of hospital discharge process and feasibility / acceptability at home.
b) Reference legislation:
- Law 833/1978 "Establishment of the National Health System"
- Legislative Decree 502/1992 and Law n. 724 of 23rd December 1994
- The Regional Health System: regional legislation (Operating rules)
- European Directives on continuity care between hospital, community and home care
- Law 328/2000 Realization of the integrated system of interventions and social services.
- National Health Plan and Essential Levels of Care (LEA)
- Law n. 38 of 15th March 2010, Provisions to ensure access to palliative care and pain therapy.

c) Actors and recipients of nursing care:
- Family nurse, case manager
- Family, person, group, community
- The multi-professional team
- The role of the caregiver in different care settings







· Preventive nursing care
Methods and tools for nursing care:
Therapeutic education for individuals, families and particular groups, with interventions on the environment, nutrition, relationships, adherence to therapy, to guarantee a good quality of life for people with chronic degenerative diseases: AIDS, tuberculosis , oncological and/or hematological diseases, aged people, with cognitive problems
Use of IADL (Instrumental Activities of Daily Living) assessment scales in the aged people at intra and extra-hospital care services
Diagnostic and therapeutic paths at home
Integrated home documentation

· Nursing care for people:
In the end of life and accompaniment to death; support to family members in the choices at the end of life and during the mourning phases
In oncological and non-oncological palliative care and pain treatment
In a condition of chronic and chronic degenerative conditions (eg. aged people, disabled, severe psycho-physical frailties
In people with oncological and / or hematological pathology (eg. immunodepressed people, oral anticoagulants therapy)

Therapeutic education project for people in chronic-degenerative conditions, family, caregivers, community in extra-hospital contexts, with particular attention to ethical implications.
Exercise (through role play or video projection) for the development of communication skills to expand palliative and end of life care

· Contest analysis and Community nursing care models
a) The network of social-health services: continuity between care settings, protected discharge project, health care services, primary care, intermediate care, home care, hospice, integrated care models, chronic care model, CreG (CronicRelated Group) , regional networks, the relationship between nurses and patient's relatives in hospital and at home, the meaning of continuity of care, the concept of hospital discharge process and feasibility / acceptability at home.
b) Reference legislation:
- Law 833/1978 "Establishment of the National Health System"
- Legislative Decree 502/1992 and Law n. 724 of 23rd December 1994
- The Regional Health System: regional legislation (Operating rules)
- European Directives on continuity care between hospital, community and home care
- Law 328/2000 Realization of the integrated system of interventions and social services.
- National Health Plan and Essential Levels of Care (LEA)
- Law n. 38 of 15th March 2010, Provisions to ensure access to palliative care and pain therapy.

c) Actors and recipients of nursing care:
- Family nurse, case manager
- Family, person, group, community
- The multi-professional team
- The role of the caregiver in different care settings







· Preventive nursing care
Methods and tools for nursing care:
Therapeutic education for individuals, families and particular groups, with interventions on the environment, nutrition, relationships, adherence to therapy, to guarantee a good quality of life for people with chronic degenerative diseases: AIDS, tuberculosis , oncological and/or hematological diseases, aged people, with cognitive problems
Use of IADL (Instrumental Activities of Daily Living) assessment scales in the aged people at intra and extra-hospital care services
Diagnostic and therapeutic paths at home
Integrated home documentation

· Nursing care for people:
In the end of life and accompaniment to death; support to family members in the choices at the end of life and during the mourning phases
In oncological and non-oncological palliative care and pain treatment
In a condition of chronic and chronic degenerative conditions (eg. aged people, disabled, severe psycho-physical frailties
In people with oncological and / or hematological pathology (eg. immunodepressed people, oral anticoagulants therapy)

Therapeutic education project for people in chronic-degenerative conditions, family, caregivers, community in extra-hospital contexts, with particular attention to ethical implications.
Exercise (through role play or video projection) for the development of communication skills to expand palliative and end of life care

· Contest analysis and Community nursing care models
a) The network of social-health services: continuity between care settings, protected discharge project, health care services, primary care, intermediate care, home care, hospice, integrated care models, chronic care model, CreG (CronicRelated Group) , regional networks, the relationship between nurses and patient's relatives in hospital and at home, the meaning of continuity of care, the concept of hospital discharge process and feasibility / acceptability at home.
b) Reference legislation:
- Law 833/1978 "Establishment of the National Health System"
- Legislative Decree 502/1992 and Law n. 724 of 23rd December 1994
- The Regional Health System: regional legislation (Operating rules)
- European Directives on continuity care between hospital, community and home care
- Law 328/2000 Realization of the integrated system of interventions and social services.
- National Health Plan and Essential Levels of Care (LEA)
- Law n. 38 of 15th March 2010, Provisions to ensure access to palliative care and pain therapy.

c) Actors and recipients of nursing care:
- Family nurse, case manager
- Family, person, group, community
- The multi-professional team
- The role of the caregiver in different care settings







· Preventive nursing care
Methods and tools for nursing care:
Therapeutic education for individuals, families and particular groups, with interventions on the environment, nutrition, relationships, adherence to therapy, to guarantee a good quality of life for people with chronic degenerative diseases: AIDS, tuberculosis , oncological and/or hematological diseases, aged people, with cognitive problems
Use of IADL (Instrumental Activities of Daily Living) assessment scales in the aged people at intra and extra-hospital care services
Diagnostic and therapeutic paths at home
Integrated home documentation

· Nursing care for people:
In the end of life and accompaniment to death; support to family members in the choices at the end of life and during the mourning phases
In oncological and non-oncological palliative care and pain treatment
In a condition of chronic and chronic degenerative conditions (eg. aged people, disabled, severe psycho-physical frailties
In people with oncological and / or hematological pathology (eg. immunodepressed people, oral anticoagulants therapy)

Therapeutic education project for people in chronic-degenerative conditions, family, caregivers, community in extra-hospital contexts, with particular attention to ethical implications.
Exercise (through role play or video projection) for the development of communication skills to expand palliative and end of life care

· Contest analysis and Community nursing care models
a) The network of social-health services: continuity between care settings, protected discharge project, health care services, primary care, intermediate care, home care, hospice, integrated care models, chronic care model, CreG (CronicRelated Group) , regional networks, the relationship between nurses and patient's relatives in hospital and at home, the meaning of continuity of care, the concept of hospital discharge process and feasibility / acceptability at home.
b) Reference legislation:
- Law 833/1978 "Establishment of the National Health System"
- Legislative Decree 502/1992 and Law n. 724 of 23rd December 1994
- The Regional Health System: regional legislation (Operating rules)
- European Directives on continuity care between hospital, community and home care
- Law 328/2000 Realization of the integrated system of interventions and social services.
- National Health Plan and Essential Levels of Care (LEA)
- Law n. 38 of 15th March 2010, Provisions to ensure access to palliative care and pain therapy.

c) Actors and recipients of nursing care:
- Family nurse, case manager
- Family, person, group, community
- The multi-professional team
- The role of the caregiver in different care settings







· Preventive nursing care
Methods and tools for nursing care:
Therapeutic education for individuals, families and particular groups, with interventions on the environment, nutrition, relationships, adherence to therapy, to guarantee a good quality of life for people with chronic degenerative diseases: AIDS, tuberculosis , oncological and/or hematological diseases, aged people, with cognitive problems
Use of IADL (Instrumental Activities of Daily Living) assessment scales in the aged people at intra and extra-hospital care services
Diagnostic and therapeutic paths at home
Integrated home documentation

· Nursing care for people:
In the end of life and accompaniment to death; support to family members in the choices at the end of life and during the mourning phases
In oncological and non-oncological palliative care and pain treatment
In a condition of chronic and chronic degenerative conditions (eg. aged people, disabled, severe psycho-physical frailties
In people with oncological and / or hematological pathology (eg. immunodepressed people, oral anticoagulants therapy)

Therapeutic education project for people in chronic-degenerative conditions, family, caregivers, community in extra-hospital contexts, with particular attention to ethical implications.
Exercise (through role play or video projection) for the development of communication skills to expand palliative and end of life care

· Contest analysis and Community nursing care models
a) The network of social-health services: continuity between care settings, protected discharge project, health care services, primary care, intermediate care, home care, hospice, integrated care models, chronic care model, CreG (CronicRelated Group) , regional networks, the relationship between nurses and patient's relatives in hospital and at home, the meaning of continuity of care, the concept of hospital discharge process and feasibility / acceptability at home.
b) Reference legislation:
- Law 833/1978 "Establishment of the National Health System"
- Legislative Decree 502/1992 and Law n. 724 of 23rd December 1994
- The Regional Health System: regional legislation (Operating rules)
- European Directives on continuity care between hospital, community and home care
- Law 328/2000 Realization of the integrated system of interventions and social services.
- National Health Plan and Essential Levels of Care (LEA)
- Law n. 38 of 15th March 2010, Provisions to ensure access to palliative care and pain therapy.

c) Actors and recipients of nursing care:
- Family nurse, case manager
- Family, person, group, community
- The multi-professional team
- The role of the caregiver in different care settings







· Preventive nursing care
Methods and tools for nursing care:
Therapeutic education for individuals, families and particular groups, with interventions on the environment, nutrition, relationships, adherence to therapy, to guarantee a good quality of life for people with chronic degenerative diseases: AIDS, tuberculosis , oncological and/or hematological diseases, aged people, with cognitive problems
Use of IADL (Instrumental Activities of Daily Living) assessment scales in the aged people at intra and extra-hospital care services
Diagnostic and therapeutic paths at home
Integrated home documentation

· Nursing care for people:
In the end of life and accompaniment to death; support to family members in the choices at the end of life and during the mourning phases
In oncological and non-oncological palliative care and pain treatment
In a condition of chronic and chronic degenerative conditions (eg. aged people, disabled, severe psycho-physical frailties
In people with oncological and / or hematological pathology (eg. immunodepressed people, oral anticoagulants therapy)

Therapeutic education project for people in chronic-degenerative conditions, family, caregivers, community in extra-hospital contexts, with particular attention to ethical implications.
Exercise (through role play or video projection) for the development of communication skills to expand palliative and end of life care

) The network of social-health services: continuity between care settings, protected discharge project, health care services, primary care, intermediate care, home care, hospice, integrated care models, chronic care model, CreG (CronicRelated Group) , regional networks, the relationship between nurses and patient's relatives in hospital and at home, the meaning of continuity of care, the concept of hospital discharge process and feasibility / acceptability at home.
b) Reference legislation:
- Law 833/1978 "Establishment of the National Health System"
- Legislative Decree 502/1992 and Law n. 724 of 23rd December 1994
- The Regional Health System: regional legislation (Operating rules)
- European Directives on continuity care between hospital, community and home care
- Law 328/2000 Realization of the integrated system of interventions and social services.
- National Health Plan and Essential Levels of Care (LEA)
- Law n. 38 of 15th March 2010, Provisions to ensure access to palliative care and pain therapy.

c) Actors and recipients of nursing care:
- Family nurse, case manager
- Family, person, group, community
- The multi-professional team
- The role of the caregiver in different care settings







· Preventive nursing care
Methods and tools for nursing care:
Therapeutic education for individuals, families and particular groups, with interventions on the environment, nutrition, relationships, adherence to therapy, to guarantee a good quality of life for people with chronic degenerative diseases: AIDS, tuberculosis , oncological and/or hematological diseases, aged people, with cognitive problems
Use of IADL (Instrumental Activities of Daily Living) assessment scales in the aged people at intra and extra-hospital care services
Diagnostic and therapeutic paths at home
Integrated home documentation

· Nursing care for people:
In the end of life and accompaniment to death; support to family members in the choices at the end of life and during the mourning phases
In oncological and non-oncological palliative care and pain treatment
In a condition of chronic and chronic degenerative conditions (eg. aged people, disabled, severe psycho-physical frailties
In people with oncological and / or hematological pathology (eg. immunodepressed people, oral anticoagulants therapy)

Therapeutic education project for people in chronic-degenerative conditions, family, caregivers, community in extra-hospital contexts, with particular attention to ethical implications.
Exercise (through role play or video projection) for the development of communication skills to expand palliative and end of life care

· Contest analysis and Community nursing care models
a) The network of social-health services: continuity between care settings, protected discharge project, health care services, primary care, intermediate care, home care, hospice, integrated care models, chronic care model, CreG (CronicRelated Group) , regional networks, the relationship between nurses and patient's relatives in hospital and at home, the meaning of continuity of care, the concept of hospital discharge process and feasibility / acceptability at home.
b) Reference legislation:
- Law 833/1978 "Establishment of the National Health System"
- Legislative Decree 502/1992 and Law n. 724 of 23rd December 1994
- The Regional Health System: regional legislation (Operating rules)
- European Directives on continuity care between hospital, community and home care
- Law 328/2000 Realization of the integrated system of interventions and social services.
- National Health Plan and Essential Levels of Care (LEA)
- Law n. 38 of 15th March 2010, Provisions to ensure access to palliative care and pain therapy.

c) Actors and recipients of nursing care:
- Family nurse, case manager
- Family, person, group, community
- The multi-professional team
- The role of the caregiver in different care settings







· Preventive nursing care
Methods and tools for nursing care:
Therapeutic education for individuals, families and particular groups, with interventions on the environment, nutrition, relationships, adherence to therapy, to guarantee a good quality of life for people with chronic degenerative diseases: AIDS, tuberculosis , oncological and/or hematological diseases, aged people, with cognitive problems
Use of IADL (Instrumental Activities of Daily Living) assessment scales in the aged people at intra and extra-hospital care services
Diagnostic and therapeutic paths at home
Integrated home documentation

· Nursing care for people:
In the end of life and accompaniment to death; support to family members in the choices at the end of life and during the mourning phases
In oncological and non-oncological palliative care and pain treatment
In a condition of chronic and chronic degenerative conditions (eg. aged people, disabled, severe psycho-physical frailties
In people with oncological and / or hematological pathology (eg. immunodepressed people, oral anticoagulants therapy)

Therapeutic education project for people in chronic-degenerative conditions, family, caregivers, community in extra-hospital contexts, with particular attention to ethical implications.
Exercise (through role play or video projection) for the development of communication skills to expand palliative and end of life care