Intensive rehabilitation services in Italy: new 2024 guidelines and general process requirements improving appropriateness and quality

Introduction

Rehabilitation services are pivotal in promoting the well-being of individuals facing health challenges (1). Following the World Health Organization (WHO) and its partners’ principles (2), Italy has embarked on a journey to enhance health system (3) and rehabilitation services, aligning them with universal health coverage principles (4). This essay delves into Italy’s recent legislative developments and guidelines, shedding light on the country’s efforts to reform its rehabilitation sector (5).

Italy’s commitment to rehabilitation dates back to 1998, with subsequent updates in 2010 (5). That time, the total hospitalizations were about 12 millions of which approximately 360,000 were in rehabilitation. Of these 294,000 in ordinary care and approximately 64,000 in day hospital (6). The national rehabilitation plan (5,7) up to the present day, certainly had several weak points. Formally, almost all the regions had their own lines dealing with the themes proposed by the national guidelines but generating multiple offering units with different names (8-10). These units have never been easily comparable due to the lack of quantitative data relating to structural and/or organizational requirements which are not always similar. Many of the regulations issued have never been applied due to the lack of common implementation tools and continuity of care is still often achieved through the sum of many individual interventions, without achieving complete and early global care of the person (9,10). To date, for example, confusion or overlap between long-term care and extensive rehabilitation persists in many regions of Italy (10). Finally, the volumes of activity and the distribution of services are very unbalanced between the different regions, either towards responses prevalent in an inpatient setting or towards responses prevalent in an outpatient setting (10-12). Last but not least, a limit has always been represented by the different reporting and pricing regimes, which are not based on the actual use of the assigned resources but which are based only on disease codes (9-12). Despite these efforts, challenges such as lack of standardization, regional disparities, and reporting issues persisted (10). In last years, with over 2.6 million people with disabilities in Italy (5), the need for a cohesive and efficient rehabilitation system became apparent (13), possibly accompanied by the introduction of a new hospital discharge form [Schede di Dimissione Ospedaliera (SDO).rehab], established (13) by decree of the Ministry of Health 28 December 1991, as an integral part of the medical record and ordinary tool for the collection of information relating to each patient discharged from public and private hospitals throughout the national territory.

Methods

In this article we narratively review old rules describing recent ones aiming to standardize rehabilitation activities across regions. Recent rules born in 2021 by means of the State-Regions Agreement on “Guidelines for the Identification of Appropriate Paths in the Rehabilitation Network” that laid the foundation for the significant forementioned Ministerial Decree in August 2022 (14,15). This decree outlined guidelines for appropriate pathways, covering transitions from hospitals to communities, day hospitals, clinics, homes, and socio-health rehabilitation. Starting from 2024, these standards and the new hospital discharge form for rehabilitation are now mandatory nationwide. The recent guidelines emphasize the integration of healthcare and social interventions, focusing on outcome-oriented approaches.

Results

The Ministerial Decree on “Criteria for Appropriateness of Access to Hospital Rehabilitation Admissions” focuses on neurologic, pneumologic, cardiac, and orthopedic cases. It introduced a one-year experimental phase (year 2023), during which existing national and regional norms for rehabilitation remained in force (14). The decree aimed to streamline resources, ensure quality care, and reduce high-risk inappropriate rehabilitation admissions. It enlightened the intricacies of the functional recovery and rehabilitation discipline, delineating three distinct levels of complexity in hospitalization based on the severity of disabling pathologies and concurrent issues (16). These levels entail varying needs for medical, nursing, and rehabilitative assistance, diverse utilization of equipment, drugs, and devices, along with distinct durations for completing rehabilitation projects: highly complex intensive rehabilitation hospitalizations, less complex intensive rehabilitation hospitalizations, and extensive rehabilitation hospitalizations. Emphasizing the imperative to enhance efficiency, rationalize resources, and elevate the quality and positive outcomes of rehabilitation treatments within hospital admission settings, the Decree defines appropriateness criteria for adult patients with specific codes indicative of neurological, pneumological, cardiological, and orthopedic conditions [Major Diagnostic Categories (MDC) 1-4-5-8]..

Discussion

Most recent rules do complete a process that began in 1998 and continued with the Rehabilitation National Address Plan in 2010 (8). Despite past efforts, challenges in defining intervention outcomes and ensuring consistent guideline application persisted up these last months. Up today, the persistent challenge in the rehabilitation sector has been above all the appropriateness, often compromised due to various reasons. That is why the Ministerial Decree of 2023 provides criteria for appropriate access to rehabilitation, addressing categories like acute and non-acute rehabilitation, clinical correlation, time intervals and diagnostic congruence. Technically, the Ministerial Decree no. 165 of 26 September 2023 introduced the integration and updating of the information collected by the SDO flow (track C) relating only to the discharges of hospitalizations carried out in rehabilitation departments (discipline codes 28, 56, 75) with the aim of providing better description of the rehabilitation hospitalization and to represent the care product also in terms of outcome. The information integration was necessary to implement the contents of the Ministerial Decree of 5 August 2021 “Criteria for appropriateness of access to hospital rehabilitation admissions (Online publication 02/02/2022)”. From 1 January 2024, the provision of data collected with track C is part of the obligations to which the regions and autonomous provinces are required for the purposes of accessing the supplementary financing paid by the state, as provided for by the State-Regions Agreement of 23 March 2005. A specific functional specification document describes in detail all the fields of the record layouts (A, B and C), the compilation methods and the permitted values. XML schemas (XSD—XML schema definition) are also available for the validation of SDO data in the. On the “Training material for completing the SDO-Rehabilitation” page, useful documentation for training operators (video lessons and support material) is now also available (14). The SDO foresee as mandatory several scales such as RCSe13 (16) that permit to compare the complexity of rehabilitation process with clinical outcomes. As reported by Italian experts of the Italian Society of Rehabilitation in a comprehensive monography (14,15), the preparation of the Decree aligns with the Agreement between the Government, the Regions, and Autonomous Provinces of Trento and Bolzano, as outlined in article 8, paragraph 6 of law 5 June 2003 n. 131. It particularly addresses the reduction of high-risk rehabilitation hospitalizations prone to inappropriateness, citing article 9-quater, paragraph 8, of the legislative decree of June 19, 2015, n. 78. (7). Furthermore, the Decree acknowledges the Health Pact for the years 2014–2016, defined in the State-Regions Conference of July 10, 2014, underscoring its commitment to implementing guidelines and appropriateness measures. The essay also sheds light on new guidelines introduced for the coding of SDO for Diagnosis-Related Groups (DRGs) (14). Conclusively, the essay underscores the evolution of national regulatory provisions in recent years, elucidating the intersection of appropriateness in rehabilitation assistance and the concurrent update of recording and coding systems through hospital discharge cards (SDO) (14). The Decree focuses on adult patients with access codes n.56 (intensive unit) and n.75 (post coma units), pertaining to neurological, pneumological, cardiologic, and orthopedic specialties [MDC 1-4-5-8]. Concurrently, new guidelines for the coding of hospital discharge forms (SDO) for DRG have been outlined, in tandem with the appropriateness aspect. The ongoing process of developing national regulatory measures in recent years concerning the appropriateness of rehabilitation care and the updating of recording and coding systems through the flows of hospital discharge forms (SDO) is now familiar to all. Certain phases have concluded with the approval of regulatory acts, while others are still in progress. The Ministry has disseminated an implementing circular, and almost all regions have now adopted the regulations. Recognizing limitations in the previous hospital discharge form (SDO), a national effort was so initiated to redefine the minimum content required for rehabilitation hospital stays. The resulting guidelines aim to create a standardized, nationally accepted system for recording and coding rehabilitation activities, fostering uniformity across regions. The configuration of the old hospital discharge form (SDO) layout showed clear limitations in its application in the rehabilitation context (9). The informational content and classification systems for diagnoses and procedures used for SDO information coding were primarily designed for acute care descriptions. Consequently, the current national record layout, despite recent additions from D.M. 261/2016, was still insufficient to provide an adequate description of rehabilitation admissions and represent their care outcomes. This deficiency poses significant challenges in accurately describing and assessing the epidemiological aspects of hospital rehabilitation cases and in evaluating the quality and appropriateness of provided care. In the absence of national guidelines, many regions had independently addressed the issue, resulting in widely varied solutions, both in the supplemental choice of the SDO layout and in defining specific coding guidelines. This new process aims to define the minimum core of informational content to be integrated into the SDO to adequately describe hospital rehabilitation admissions (discipline codes 56, 75, 28) introducing a nationally unified and shared rule system that allows rehabilitation hospital ward operators (of wards with codes 56, 28, and 75) in all regions to use the same criteria for completing and coding the SDO at the patient’s discharge. The old national SDO flow in use up to December 2023 (D.M. 261/2016) envisages one main diagnosis field, five secondary diagnosis fields, and up to 11 fields for procedures/interventions. The new SDO indeed, allows the comparability between Italian regional health systems, a correct reading of the activity in the national indicators and a better and more specific description of the cases through diagnosis and interventions.

Conclusions

Italy’s recent legislative developments in rehabilitation signify a comprehensive effort to address historical challenges and improve the overall effectiveness of rehabilitation services. The State-Regions Agreement, Ministerial Decree, and updated hospital discharge form aim to standardize practices, enhance appropriateness, and ensure a seamless transition from hospital to community-based care. While challenges persist, these initiatives mark a significant step towards a more integrated and efficient rehabilitation system in Italy. The reorganization of the hospital discharge summary (SDO) within the context of rehabilitation represents a critical area of focus. This process aims to improve the management of hospital admissions for patients requiring rehabilitation. However, the complexity of this endeavor arises from multiple factors, including the significance of the topic for healthcare policies, the involvement of diverse stakeholders, and the economic and social implications. Despite the challenges and limitations previously described, these measures represent an initial response to urgent needs. These needs include achieving greater uniformity and transparency in SDOs, as well as providing an updated and accurate description of rehabilitation requirements, delivered services, and outcomes. It is hoped that these measures can also help reduce excessive disparities in behavior at the regional level. The introduction of specific indicators related to functional level and rehabilitation complexity, along with the adoption of validated scales tailored to these aspects, marks a significant turning point for the rehabilitation sector. Historically, this sector has expressed dissatisfaction with information flows that were overly modeled on the acute medical and surgical fields. This regulatory evolution presents both a challenge and an opportunity for clinicians. As stated by Italian eminent authors (7), it entails the responsibility of adequately documenting clinical conditions for appropriateness purposes, while also allowing for a more precise and accurate description of the needs of individuals under their care, the services provided, and the outcomes achieve.

Acknowledgments

Funding: None.

Footnote

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-11/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-11/coif). The authors have no conflicts of interest to declare.

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