Keywords

1 Introduction

Territorial care services are a fundamental part of the whole healthcare network of assistance, prevention, and health promotion with specific qualities of healthcare facilities (Brambilla et al. 2021a, b; Capolongo et al. 2015; Wilhelm and Battisto 2020). The literature has shown that health systems with “strong” primary and proximity care services have also better population health outcomes (Rifkin 2018), defined by the WHO as a fundamental human right (World Health Organization 2020; Capolongo et al. 2021; Starfield et al. 2005). In fact, in 2019, the latter included primary care among the most relevant humanitarian threats to be solved with the new 5-year strategic plan to achieve the universal health coverage, protection from health emergencies and more health accessibility.

The global SARS-CoV-2 pandemic has underlined the crucial role of community health, especially in Italy (Vinceti et al. 2021; AGENAS 2021) where interactions between the different levels of healthcare systems, excessive waiting times in the provision of health services, and their unequal territorial distribution were particularly problematic (Filippini and Vinceti 2021). (AGENAS 2021). The Italian peninsula currently lacks proximity structures and telemedicine for territorial healthcare assistance to decrease inequalities in healthcare access and improve healthcare overall services. Community Homes (“Case della Comunità”—CdC) and Community Hospitals (“Ospedali della Comunità”—OdC) are among the responses to the problem that the Italian government has decided to implement through the recovery and resilience plan (Gola et al. 2020). These new territorial structural typologies (Fig. 88.1) aim to provide more sustainable, uniform, inclusive, and equitable healthcare by fitting into the existing National Health System with two different objectives reflecting the following definitions:

Fig. 88.1
A layout of the healthcare system consists of different housings of C D C, O D C, homes, and commercial buildings with trees.

New territorial healthcare system in Italy. Personal elaboration by the authors, 2021

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  • Community Homes are multi-purpose facilities that are easily recognizable and reachable and that will allow patients to get in touch with all the health, social, and health services offered by the NHS on a territorial scale. These facilities promote an integrated and multidisciplinary intervention model by providing needs assessment, orientation to services, integrated planning, and management of home care, ensuring continuity of care, targeted assistance to chronically ill and frail patients (DM71).

  • As defined by Ministerial Decree 2 April 2015 n. 70, Community Hospitals are territorial intermediate healthcare facilities for short-term stays that aim to improve the quality and appropriateness of care while avoiding unnecessary hospitalizations and improper access to hospitals. They are for patients who require low-intensity clinical interventions and continuous nursing care and supervision, which cannot be provided at home. Furthermore, these two new facilities will be geared toward social inclusion and well-being, sustainability and climate resilience, energy and plant efficiency, and the safety and security of users and all citizens, in accordance with the main international guidelines (2030 Agenda for Sustainable Development and its 17 Sustainable Development Goals, SDGs; the European Green Deal, the Urban Health Rome Declaration).

2 Objectives of the Study

Despite the National Healthcare System has already introduced local healthcare buildings and facilities, each Italian region applied them in various ways and no systematic frameworks are available for mapping and comparison; in fact, regions have defined very different accreditation standards from each other. Italian Government provided a document (Dossier n° 144 of the Italian Chamber of Deputies, 2021) which lists the regional legislations about local healthcare facilities, but it is missing a model that compares and collects the accreditation standards required by each Italian region.

The lack of data collection and awareness on such healthcare facilities is also part of the research gap formulation (Banchieri 2021).

Therefore, the objective of this study is to outline the framework about regional accreditation standards for local healthcare facilities, providing the general understanding of the technical and performance-based requirements of such healthcare infrastructures. Moreover, since these local healthcare facilities have been recently introduced in the PNRR, thanks to this analysis, it was possible to find out which Italian regions had already enacted their own legislation with specific accreditation standards for these buildings. The relevance of this paper is therefore to reflect the generally acknowledged about of both territorial healthcare facilities needs, spatial, functional, technological, and organizational standards that can be useful for designing new local healthcare buildings and facilities as well as for guiding the remodeling/restructuring of existing ones.

3 Methods

The research grounds on the PNRR document and the release process of Ministry of Health Decree D.M.71 on “Standards and Models for the Territorial Healthcare Development in the NHS” which provides some general guidelines for the new local healthcare facilities defined inside the national PNRR document and have been anticipated by several draft documents that have been used as the starting point of the study. Even if they cannot be considered official accreditation standards, they contains very useful information about activities (as mandatory and recommended functional areas), technological (as plants and medical equipment), and organizational features (as staff type).

From the methodological perspective, it was important to understand the definition of accreditation standards for buildings and facilities provided by the Italian national legislations: Legislative Decree DL 502/92 defines 3 different kinds of them, as minimum performances that facilities and building have to guarantee. As reported in DL n. 502/92—in both the initial draft, and the following updates—and in D.P.R 42/1997, accreditation is a right that must be provided to all facilities that can reach the minimum required performances. Then, it was necessary to discover which national and regional laws define accreditation standards for the existing local healthcare buildings and facilities in Italy. For this step of the research, 10 national documents have been studied, among them, it was Dossier n° 144 of the Italian Chamber of Deputies “Case della salute ed Ospedali di comunità: i presidi delle cure intermedie. Mappatura sul territorio e normativa nazionale e regionale”, which provide a list of the regional legislations about local healthcare facilities, especially referred to “Healthcare Homes (Case della Salute-CdS)” and to OdCs. Since CdCs have been recently introduced in Italy, both national and regional accreditation standards, which are currently in development.

Anyway, CdCs can be considered as an evolution of CdSs (Banchieri 2021), so regional accreditation standards for CdSs have been examined for this analysis. In facts, in Italy, the existing local healthcare facilities are CdSs and OdCs, and regions which introduced them have already provided to define their own accreditation standards.

From the list of regional legislations reported in Dossier n° 144 of the Italian Chamber of Deputies, 62 documents about local healthcare buildings and facilities have been studied, looking for which of them provide accreditation standards for these kind of facilities.

Qualitative and quantitative differences emerged regarding accreditation standards provided by each region (Fig. 88.2): in fact, through researching keyword such as “performance”, “accreditation”, and “standard”, it has been discovered that just 7 regions out of 20 provided accreditation standards for CdSs, as well as 7 regions out of 20 for OdCs. The full list of regulation analyzed provided in Fig. 88.1 has been considered for this study; each document has been read and reviewed by the authors, and the specific requirements for OdC and CdC provided by the different region have been highlighted and collected in a systematic and structured way.

Fig. 88.2
A text in a foreign language.

List of documents analyzed both at national and regional level

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Indeed, a comparative matrix has been chosen as the methodologic strategy for collecting and effectively categorizing the accreditation standards found. Four macro-categories for the analysis of regional standards have been used as well as sub-categories, as reported below:

  1. (I)

    Catchment Area—Standard, about the number of users of the single facility. PNRR gives specific information about the catchment area:

    • type “Hub” 1/100.000 residents;

    • type “Spoke” divided into 3 sub-categories: (Metropolitan Area: 1/30–35.000 residents; Urban/Sub-urban Area: 1/20–25.000 residents; Rural Area: 1/10–15.000 residents).

  2. (II)

    Structural standards collect minimum spatial and dimensional requirements provided by each regional legislation. This class is divided into 3 sub-categories: minimum dimensions of the building; list of the functional area (which reports information about typology, minimum quantity, and dimensions), single units (which provide indications about typology of the single locals, minimum quantity, and dimensions).

  3. (III)

    Technological standards structured in to 2 sub-categories: typology of plants and minimum performance required.

  4. (IV)

    Organizational standards which provide information about healthcare, socio-healthcare, nursing and technicians staff, reporting typology, and quantity defined by each Region.

4 Results

Community Homes. It was possible to find available documents about CdSs and CdCs for 7 Italian regions: Calabria, Emilia-Romagna, Lazio, Marche, Molise, Sicilia e Toscana. Results are reported in the Fig. 88.3. The presence or absence of specific data in each document is reported with a binary system of yes(Y) or no(N) items (Fig. 88.3).

Fig. 88.3
A table of categories, regions, catchment area standards, and details about home characteristics displays data on structural requirements, dimensions of the structure, rooms and spaces, system requirements, and healthcare, among others.

Matrix of Community Home characteristics in different Italian region

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Community Hospital. It was possible to find the legislation containing the accreditation requirements for Community Hospitals in 7 regions: Abruzzo, Emilia-Romagna, Lazio, Lombardy, Marche, Tuscany, and Veneto. For convenience in consulting the results, the contents are summarized in Fig. 88.4. The presence or absence of specific data in each document is reported with a binary system of yes(Y) or no(N) items (Fig. 88.4).

Fig. 88.4
A table of categories, regions, catchment area standards, and details about home characteristics displays data on structural requirements, dimensions of the structure, rooms and spaces, system requirements, and healthcare, among others.

Matrix of Community Hospitals characteristics in different Italian region

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5 Discussion

This research is the first step of a bigger project of the National Agency for Regional Healthcare System (AGENAS), which main objective is to define metadesign guidelines for the new local healthcare facilities, using actual regional accreditation standards as background. So, this research project helped AGENAS to map the state of the art and collect in a single document all the design standards defined by each region, useful for eliciting national metadesign guidelines. Moreover, there are strict time limits for deploying this project at the national level: in facts, PNRR established the intent of the Italian Government to realize at least 1350 CdCs by the year 2026. For this reason, mapping accreditation standards at the regional level is fundamental to speed up the definition of national guidelines for designing these facilities. Moreover, another positive aspect is that the existing local healthcare facilities can be considered as very useful case studies for designing the new ones. But, on the other hand, the existing framework is confused, as the identity of these facilities, and every regional legislation is very different among each other. Starting from this study, preliminary challenges for defining CdC and Odc are reported below.

5.1 The Challenge for Defining Community Homes (CdC)

PNRR has allocated EUR 2 billion for the realization of 1288 CdCs by the first half of the 2026, local facilities which provide primary healthcare and social healthcare services.

CdCs are divided in to 2 different kinds, related to the complexity of healthcare and social healthcare services provided: The most advanced ones are called “Hub” by the PNRR document, and their catchment area is 1 every 100.000 residents; but, there are even smaller CdCs, called “Spoke”, which have 3 different catchment areas: Metropolitan Area: 1 every 30–35.000 residents; Urban/Sub-urban Area: 1 every 20–25.000 residents; Rural Area: 1 every 10–15.000 residents. This regional requirement is in line with the national suggestions.

Generally speaking, these facilities provide services as: medical check-up; reception; services for continuity of care; general medicine; polyclinics; first aid; first-line diagnostics services; sampling point; rehabilitation; homecare services; primary care pediatricians; vaccination center; screening; social healthcare services; telemedicine.

The functional areas have different spatial units as: hall; sanitary facilities both for users and for staff; archives; offices; locker rooms for staff; relaxation room; clinic rooms; scan room; x-ray room; rehabilitation gym.

Since the list of function is very variable in the national territory and reflects the peculiarity of each regional system, the maximum level of flexibility in national standards as well as in the design or refurbishment of such infrastructures should be guaranteed (Brambilla et al. 2021b).

Finally, these facilities will have conventional systems and equipment such as air conditioning system and emergency lightings but some region provide information about the installation of Internet of things sensors.

Finally, only 57% of the regional legislation studied provides information about types of staff for CdCs or CdSs: general doctor; primary care paediatricians; specialist doctor; nursing staff; social healthcare staff; administrative personnel; healthcare professionals.

5.2 The Challenge for Defining Community Hospitals (OdC)

OdCs are facilities which provide intermediate healthcare level services, and PNRR has allocated EUR 1 billion for designing 381 OdCs by the first half of the 2026.

They can host a variable number of beds, which is indicated at national level of 20 or 40 but highlighted in regional documentation from 8 to 25. This discrepancies should be carefully considered in the strategic planning and design. Only 29% of the regional legislations of this study provides information about functional areas as: reception; hospitalization (max 4 beds per room) and rehabilitation; healthcare services; support services; morgue area. On the contrary, specific attention has been dedicated to single environmental unit as data have been provided by 86% of the regional legislation studied: single room (9–12 m2); multi-occupancy room (16–30 m2); sanitary facilities both for users and for staff; archives; waiting room; relaxation room; rehabilitation gym; offices; morgue; staff rooms.

These facilities will have special and conventional systems and equipment as reported by 71% of the regions: air conditioning system; emergency lighting; system for medical gas administration, and Internet connection, configuring the OdC as a functional hospital ward.

Finally, in each OdCs, it is recommended to have a multidisciplinary staff, composed by: clinical manager; general doctor; specialist doctor; nursing case manager; primary care paediatricians; psychologist; physical therapist; social worker; nurse; just one region provided quantitative information about staff workforce needs.

6 Conclusion

6.1 Final Remarks and Outlooks

The analysis and comparison of regional regulations have brought out evident differences in the quantity and type of indications provided. The result obtained confirms the initial hypothesis about the needs to map and compare Italian region guidelines and position this study as a meaningful starting point to further extrapolate the common and virtuous factors to be considered in the national guidelines. In fact, each regional contribution can offer insights for the development of macro-project about national meta-design guidelines definition as much more comprehensive, effective, and high quality as possible: a contribution that remains significant despite each region is unique and influenced by its own territorial, socio-economic, and epidemiological characteristics.

6.2 Research Limitations and Further Development

The novelty and time dependence of this issue represent the main limitation of the research. In fact, at the time of data collection, no region had yet decided on accreditation regulations for Community Homes, and less than half had provided indications regarding the similar type of “Health Homes” and Community Hospitals.

In addition, the matrices could be implemented with other types of information useful at the operational level for the implementation of these facilities, such as the time and cost of implementation, information which, however, currently no region has provided.

Starting from these limitations, the systematic collection of data presented is the starting point for several further research developments. Among these, the tables could become an operational tool used by decision-makers to sort, monitor, and map what has been decided within each regional regulation. In addition, if the cataloging method of each region was shared at national level, this would encourage synergy, communication, and virtuous competition between the different territorial healthcare systems and infrastructures.