Short Communication

The role of a Family and Community Nurse in a Country Nursing Home in a major metropolitan hospital in Lombardy, Italy


Marco Bosio*, Silvia Colombo, Laura Zoppini, Simona Giroldi, Mauro Moreno

ASST Grande Ospedale Metropolitano Niguarda, Piazza dell’Ospedale Maggiore, Milano 320162, Italy


Corresponding author:

Marco Bosio, E-mail: direzionegenerale@ospedaleniguarda.it

For reprints contact: reprints@sppub.org

Received 01 April 2022; Accepted 02 July 2022; Available online 27 October 2022



At a demographic and epidemiological level, the modern era had radical unprecedented evolutions, such as to condition a profound change of the emerging needs of the population, particularly at the social and health level. Firstly, the increase of life expectancy conditioned a demographic redistribution which will lead to doubling of the proportion of elderly people by 2050, which will go from 11% to 22% of the total population, with a major increase in absolute terms in the segment of those over eighty years old.[1,2,3,4,5,6,7,8,9] Secondly, there was an epidemiological transition in emerging pathology, with a major prevalence of chronic-degenerative conditions to which, particularly in the most developed and high-income countries, the Global Burden of Disease, measured in Disability-Adjusted Life Years is attributed.[2] Consequently, the load of disabilities, resulting mainly from non-communicable diseases, will increase proportionally to the growth of the population, with a higher percentage precisely in the older age groups, with a high impact on the responsiveness of the national health systems. Therefore, it is necessary to timely implement health policy initiatives that promote the protection of health[6] particularly through the application of models of care and assistance of integration and continuity, reducing hospitalization and prioritizing interventions on the territory. These interventions will have an orientation towards prevention, rehabilitation, environmental facilities, economic, social, and motivational support for the elderly and their family, in the context of life.[9]


In this context and in this perspective, at the national level, the Italian Ministry of Health has recently issued guidelines for the relaunch and innovation of the country and the National Health Service, aiming in particular on the strengthening and reorganization of territorial and extra-hospital health services.[10] On the national territory, the plan provides for the construction of 1,288 proximity structures by 2026, called “Case della Comunità” (CdCs), a sort of country nursing home as described below, as a reference point for the response to social and health needs for the local reference population with multidisciplinary and multi-professional logic intervention.[8] In the Lombardy region, the most populous Italian region with about 10 million inhabitants, the implementation of the new structures determined by the Recovery Plan is part of a development path of the Regional Law 23/2015 aimed at consolidating hospital-territory continuity through the reorganization of the hospital and its reference area and foresees the development of 203 CdCs, of which 2 will concern the territorial area of the Niguarda Hospital.


The quantity of available resources is such to require careful planning and speed of intervention to allow them to be spent on schedule.


The paper aims to describe the organisational model of Niguarda Hospital in the development, according to national standards,[11] of the CdCs within the district of competence through proposing a model of hospital- territory integration, taking charge and continuity of care focused on:


Niguarda is a large metropolitan hospital home to all clinical and surgical specialities for adults and children, with social and health skills for territorial care. The combination of these two souls defines its orientation: to integrate specialised care with territorial health social activities, in synergy with all the actors involved in citizens’ health protection. Thanks to the local services and facilities and the collaboration with external institutions, Niguarda Hospital manages the entire process of treating chronic patients even outside the hospital walls, in a logic of socio-assistance continuity.


Consistent with the national guidelines, visible and easily accessible locations for the reference community have been identified for the realization of the territorial CdCs, i.e., those served by public transport, as well as already active for years in the provision of health and social-health activities aimed at citizens, in particular those suffering from chronic-degenerative and/or more vulnerable.


An example is given of the CdC which will be based at the territorial facility called “Villa Marelli”. This territorial facility is today already home to the main services provided for the CdC and in particular: a blood draw point; general practitioners’ practice; specialist outpatient clinics in the cardiology, respiratory, metabolic fields, i.e., for high prevalence pathologies; diagnostic services also aimed at monitoring chronicity (ultrasound, electrocardiograph, spirometer, X-ray, CT scan); IT integration with the company and regional single booking system; telemedicine tools in particular for the follow-up and reassessment of therapeutic- assistance plans, and remote reporting; an IFeC service currently active both for the surveillance and assistance of symptomatic people in home isolation for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection coordinated by a monitoring centre, and for the care of patients discharged home from hospitalization and residing in the municipality of reference. The IFeCs also carry out screening activities, such as that promoted in a pilot regional study for chronic hepatitis from virus C (HCV) and participate in the massive the coronavirus disease 2019 (COVID-19) vaccination campaign, guaranteeing both COVID-19 and flu vaccines directly at vulnerable patients’ home. There are also many other activities already promoted by the IFeCs aimed at patients and caregivers, for example in promoting the individual empowerment of the assisted person, in order to improve their ability to “cope” with the disease and develop self-care skills.


Upon completion, additional functions that are necessary or in any case recommended for a complete CdC for the territorial district of reference will be implemented, including: a H24 medical assistance coverage methods and relationships with intermediate care facilities as well as other health.


Professionals such as speech therapists, physiotherapists, dieticians, rehabilitation technicians, social workers, etc. according to the patient’s needs; offering screening programs, mental health services, addictions, child and adolescent neuropsychiatry, counselling activities and vaccinations; offering of complex nursing care, with nursing presence H12 and 6/7, in health promotion, prevention and participatory management of individual, family and community health processes as well as taking charge of the reference community also through multidimensional assessments (health and social services); community participation through citizens’ associations and voluntary work.


At the organizational level, both the positive experience for the management of the COVID-19 health emergency through the IFeCs and the well-established model of integrated hospitalterritory management of those who are chronically ill or more vulnerable through the role of the Case Manager nurse (CM) and the interaction with the volunteer in the main care pathways aimed to guaranteeing both individual and group or community interventions, combined with the orientation to disease management and the patient-centred approach as well as the connection with a hospital facility that provides all services and levels of care throughout the lifetime of the patient, has oriented Niguarda Hospital in the proposal of a network model of territorial nursing with a double matrix,[12] as described in Figure 1, for the CdCs management.


Figure 1
Figure 1: Double matrix nursing organisational model. Source: “Nursing profession in the territorial network in the light of the PNRR: scenarios and perspectives”.[12] CdC: case della comunità; IFeC: infermiere di famiglia e comunità; COPD: chronic obstructive pulmonary disease.


IFeCs are located on the horizontal axis of the matrix, in a ratio of 1 to 2,000–3,000 inhabitants, which act on a plan of continuity and taking charge of the patient in prevalent connection with the General Practitioner, guaranteeing complex nursing interventions for health promotion, disease prevention, nursing assistance to the individual, the family and the community both in the domestic and community setting, promoting the empowerment of the patient knowing in depth the problems of the patients, reporting to the case manager nurses those patients with specific clinical assistance problems that present problems of therapeutic adherence or that require targeted and/or continuous interventions and monitoring in relation to the symptoms presented. In addition, they guarantee the assistance response to the onset of new expressed and potential health and social health needs that persist in a latent way in the community.


On the vertical axis are placed the CM nurses who act on a clinical care level. They have an in-depth knowledge of the problems related to a specific chronic pathological frame (heart failure, diabetes, etc.) and they work in collaboration mainly with outpatient or hospital specialists. They act proactively with groups of patients by implementing training, monitoring interventions even remotely with telemedicine tools on significant parameters; in relation to protocols shared between GPs and specialists, they can also make changes to the therapy (e.g., suspension of the diuretic for one day in case of signs of excessive dryness, taking an additional diuretic to those prescribed in case of oedemas, etc.) and report the patient to the GP or specialist, as appropriate, for an additional evaluation.


The evolution of the National Healthcare System(NHS) in progress, which aims at a reform of primary care by making accessible to the citizen an integrated, complete, multidimensional, continuous, proactive assistance intervention, oriented to the patient and his life context, operating on a primary, secondary and tertiary preventive level directly in the area or community of reference, the great goal of protecting the well-being of the citizen is set, supporting the best possible quality of life even in the presence of disease, including polypathological.


In addition to the specialist and rehabilitative treatment of the disease, a task that remains essential, the goal that must be set is to implement prevention interventions capable of minimizing the main risk factors and promote adequate lifestyles at all ages, facilitating at the same time, access to services and the integration of the subject in his own social context.[9]


In the current demographic and epidemiological context, the district institution of a Community Nursing Home and the availability of professional Family and Community Nurse for reference population cells, who work deeply integrated with the services of the territorial welfare network - as well as hospital - aims to effectively guarantee continuity of assistance and an across-the-board approach to the needs of citizens. This will ease accessibility to the various units of offer and will promote the global response to the multidimensionality of care and assistance needs.


Niguarda Hopsital already has all the services and connections provided for by the guidelines and national standards of the CdCs, for whose full functioning for the purposes of real taking charge, integration, and continuity it proposes the application of an organizational model focused on the role of the family and community nurse, with a double matrix, in close multi-professional synergy. This will promote the development of an organisational culture fully centred on the patient, attentive to the assistance needs of the individual in his life context and reference, towards a new accessible, close, and proactive healthcare.


Source of Funding

This research received no external funding.


Conflict of Interest

The authors declare no conflict of interest.


  1. Kinsella K, He W. An aging world: 2008. US Census Bureau. Washington: US Gov Printing Office, 2009.
  2. World Health Organization. World Health Day 2012: ageing and health: toolkit for event organizers. 2012. Available at: https://apps.who.int/iris/handle/10665/70840. Accessed October 28, 2021.
  3. Lombardy Region, Regional Law n. 22 “Amendments to Title I and Title VII of the Regional Law 12/30/2009 n. 33 (Consolidated Law on Regional Health Laws)”. 2021. Avaiable at: https://www.polis.lombardia.it/wps/portal/site/polis/DettaglioRedazionale/news/2021-testo-unico-leggi-regionali-sanita. Accessed January 22, 2022.
  4. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet 2006;367:1747–1757. DOI: 10.1016/S0140-6736(06)68770-9
  5. United Nations. World population ageing 1950-2050. 2022. Available at: https://www.quotidianosanita.it/studi-e-analisi/articolo.php?articolo_id=88528. Accessed October 10, 2021.
  6. Bozzi M. Health professions training: new needs of the population and needs of organizations. 2020. Available at: http://www.quotidianosanita.it/studi-e-analisi/articolo.php?articolo_id=88528. Accessed October 25, 2021.
  7. Istat. Annual report, The situation of the country - 2020. 2020. Available at: https://www.istat.it/it/archivio/244848. Accessed October 28, 2021.
  8. WHO. Remains firmly committed to the principles set out in the preamble to the Constitution. 2022. Available at: https://www.who.int/about/governance/constitution. Accessed October 23, 2021.
  9. Galluzzo L, Gandin C, Ghirini S, Scafato E. National Center for Epidemiology, Surveillance and Promotion of Health, National Institute of Health. Population aging: opportunity or challenge? Public health epidemiology. 2012. Available at: https://www.epicentro.iss.it/ben/2012/aprile/2. Accessed October 15, 2021.
  10. Piano Nazionale di Ripresae Resilienza NextgenerationItalia. 2021. Available at: https://www.governo.it/sites/governo.it/files/PNRR.pdf. Accessed October 28, 2021.
  11. National Agency for Regional Health Services – AGENAS. Models and standards for the development of Territorial Assistance in the National Health System. 2021. Available at: http://www.quotidianosanita.it/allegati/allegato3566666.pdf. Accessed October 18, 2021.
  12. Bona A, Laquintana D, Zoppini L. Nursing profession in the territorial network in the light of the PNRR: scenarios and perspectives. Milan: Management training course for Executives of Healthcare Companies (DIAS), 2021.