Background and objective:
Difficult discharges are defined as those characterized by situations of permanent or temporary disability, resulting from an acute event, which requires economic, human, and organizational resources, which go beyond the potential of the patient and his social network, requiring the involvement of integrated home care services, long-term hospital stays, nursing homes, and hospices. The need for these services is often unpredictable and the timing of access is lagged. That increases the duration of hospitalizations and reduces the optimization of beds and professionalism of acute hospitals. During the pandemic, one cause of difficult discharge was the lack of territorial availability to welcome fragile COVID+ patients, as well as the difficulty of implementing physical isolation at home in clinically stable patients.

Methods:
In 2000, continuity of care service (SECC) was set up in our hospital, managed by 7 social workers, who can be activated directly by CCE by the case manager following a difficult discharge forecast. Following activation, the SECC interfaces with the patient to assess the health and social needs and, if necessary, with the territorial network of the most appropriate services, optimizing the reception times of the request.

Results:
In the last two years of activity, 5555 patients have been reported and managed. Of these, integrated home care was activated for 30.7%, 19.3% were sent to rehabilitation, 18.5% were managed at home, 10.7% in RSA, 6% in hospice, 4.3% were sent to the spoke network, 1.3% in subacute cases, 8.2% of requests not handled due to death, 1.1% of covid patients were hosted in our guesthouse.

Conclusion:
A better hospital-community integration, also thanks to ad hoc trained personnel to manage their interactions, including communication, can be helpful in reducing the managerial impact of difficult discharges and ensuring the appropriate use of hospital resources for acute care.