• integrated management system
• Post OLT management
• post OLT patients’ needs
• technological support
• telematic network

Background: Chronic diseases stand for a major public health problem, being the leading cause of death in developed countries. Their increase has led to the re-organization of the healthcare systems aimed at characterizing the hospitals as a place for the treatment of acute patients and implementing the chronic care model in many countries of the world.
Nevertheless, the success of liver transplantation together with limited human and infrastructural resources have caused an increasing difficulty in dealing with post transplant management both in routine and urgency. These factors call for a management network able to ensure effective continuity of care for patient needs in the post-transplant period.
Materials and methods: An observational study of prevalence has been carried out with the primary objective to evaluate patients’ needs and criticalities both in the routine daily life and in urgency in the post-transplant period and the capacity of the regional health system to support them. A survey, using a semi-structured questionnaire consisting of 30 questions, was administered to all patients residents in Tuscany, transplanted from 2000 to 2010. The survey tool assessed the followings: socio-demographic data, personal, family and social difficulties, problems emerged in the clinical routine and urgency, resolution modality, relationships with the general practitioner and the referral specialist, services the patients would appreciate to receive in their province of residence.
Results: 346 patients were matching the inclusion criteria of the study, 324 gave a telephone consent to participate to the survey and 225 responded (69.4%). The major occurred difficulties were: depression (39.5%), difficulty in returning to work (29.3%), low income (22.6%), lack of self-sufficiency (22.6%), addictions (19,1%) (tabagism 16.4%), 12.4% eating disorders, 18,9% others (social isolation, absence of a family network, etc..). The main reasons for dissatisfaction were: difficulty to obtain the required labs tests, lack of a reference structure at the local health facility. Few patients have a referral specialists in their area and most of them primarily refer to the Transplant Center even later after the procedure.
Discussion: An integrated management network between the Transplant Center and the local facilities (hospitals, general practitioners, first aids, centralized laboratories) should be implemented with the support of a telematic network in order to guarantee a direct communication system among facilities. Screening tests for some risk factors (depression, addiction, eating disorders) and services such as counselling, dietary support, rehabilitation and social services should be implemented locally.
The fundamental aspects of the service network should be focused on patient care through multidisciplinary teams management and shared plans based on risks assessment depending on the adherence degree and the health status. The network should ensure: continuity of care among the health facilities in Tuscany dealing with the follow-up care after OLT (both in routine and urgency), post-OLT complications control and appropriate use of resources. A pilot project on a small area will started to evaluate network costs and benefits. Subsequently, the project can be extended at regional and interregional level.