Continuity of Care and Home Care / organization of a process to improve the integration with the territorial health care facilities and the involvement of the family for a safe discharge of chronic patients

Objectives The increase in paediatric patients suffering from chronic disease, often involves the transfer between different care sectors. The transition from the protected hospital environment to the patient’s home is often faced with difficulties and discomfort. Therefore it is essential to ensure proper management of the course of treatment and care of the child and his family, from admission to return to home, as a single longitudinal and transverse episode. The transition phase invests heavily on empowerment of the patient and the family, as a necessary condition for safe care in self-management.