How we provide assistance to our users
We apply a multidisciplinary approach to patient care and management.

The planning of care activities is essentially based on an initial assessment of the patient by a multidisciplinary team and the drafting of the Individual Assistance Plan (PAI) or the Individual Rehabilitation Project (PRI) depending on the care setting in which the patient is placed .

Multidisciplinary Team
Within our Multidisciplinary Team, each professional contributes to the achievement of the goals of care and assistance set for the true well-being of our users.

Operationally, this translates into project-based work, which is continuously monitored to allow an effective personalization of assistance.

The Multidisciplinary Team is composed by: doctor, psychologist, nurse, physiotherapist, occupational therapist, speech therapist, social worker, healthcare assistant. These professionals all work together for the achievement of the best possible well being of the patient. The Team elaborates projects and general programs and plans all activities for each user. The professionals meet regularly to verify results and adjust the plan in order to ultimately reach the set goals.

Individual Assistance Plan (PAI)
PAI is the methodology we put in place to plan the assistance we provide to our Nursing Home users.

PAI represents the global project set up for each patient and it derives from:

• Evaluation of clinical aspects of medical expertise;
• Nurse and health care assistant assessment;
• Identification of physiotherapy needs;
• Assessment of personal, relational and social needs by the educator, the social worker and the psychologist;
• Evaluation of problems relating to communication or dysphagia problems carried out by the speech therapist.
  
  

When setting up a PAI the patient is assessed completely, beginning from the reasons for admission all the way to the goal setting. Goals must be concrete, measurable and congruent with the patient's general health framework.

The PAI is a synthetic document that contains, from a multidisciplinary point of view, the assessment of each patient with the purpose of setting a starting point for the treatment project and its main goal is the user's wellbeing. It is drawn by the Multidisciplinary Team immediately on admissione and subsequently reviewed according to the needs of the patient and in compliance with current legislation.

The PAI is shared with the patient, their family or guardian, in an understandable and appropriate manner. This approach allows to share problems and possible splutions and encourages communication.

The multidisciplinary team considers all information collected and defines the possible specific objectives, keeping in mind however that the expected output is the best possible well-being of the person, despite the illness and disability.

Individual Rehabilitation Plan (PRI)
The Individual Rehabilitation Plan consists in the set of proposals developed by the multidisciplinary team.

Individual Rehabilitation Plan (PRI):

• Contains details about the Doctor in charge of the plan
• It takes global account of the needs and preferences of the patient (and/or his family, when necessary), his impairments, disabilities and, above all, his residual and recoverable abilities, as well as environmental, contextual and personal factors;
• It defines the desired outcomes, expectations, and priorities of the patients, their families when necessary, and the caregiving team.
• It must demonstrate the awareness and understanding, by the entire team, of all the patient's issues, including aspects that may not be subject to specific interventions, and typically may not involve quantification of the aforementioned aspects, but rather provide a description in qualitative and general terms
• It defines the role of the team, composed of adequately trained personnel, concerning the actions to be taken to achieve the desired outcomes
• It outlines, in general terms, the short, medium, and long-term objectives, the expected timelines, actions, and necessary conditions for achieving the desired outcomes
• It is discussed in an understandable and appropriate manner with the patient ahd their family/caregiver.
• it is shared with all staff involved in the plan itself
• It serves as the reference for every intervention carried out by the team.
• It should be modified, adapted, and communicated again to the patient and operators if there is a substantial change in the elements upon which it was elaborated (needs, preferences, impairments, residual abilities-disabilities, environmental and resource constraints, expectations, priorities), also in relation to the previously defined timelines, actions, or conditions.
  
  

Personnel Identification
Personnel identification is ensured through an identification badge that displays the name, first initial of the surname, the professional title, and the operator's identification number.

For better identification, different professional roles are distinguished by the color of their uniforms.