The Nino Masera Foundation for the Welfare of Older People, gives support to older patients when they return home after surgery.

The Foundation takes responsibility for the nursing care which patients, just discharged from the hospital, need and for which their family does not know how to adequately respond.

The service, called “a bridge between hospital and territory“, is aimed at the older population (usually those older than 70 years of age), mainly hospitalized in the Department of Surgery of INRCA, with a well defined prognostic path. The patient is clinically stable, but is still in a condition of general fragility as to make assistance from their family problematic.

A nurse accompanies the older person in the critical transition from hospital to home, favoring the post-operative convalescence and accelerating the path to full recovery or taking charge of dealing with local services.

Some routine tests and procedures can also be scheduled during the preparatory phase of surgery to facilitate the admission of the older person to hospital.

In addition to providing basic nursing support, such as blood sampling in seniors with mobility problems, measurement of vital signs and support in preparing for exams required for diagnosis or prognosis in the pre or post-operative phase, our nurses also serve as social support. He/she is in fact a link between the user and the world surrounding the older patient, ensuring greater peace of mind, and at the same time strengthening confidence in dealing with the welfare system with which the older patient comes into contact (e.g., informing the patient on how to behave at home after the intervention, monitoring the diet, verifying the suitability of the home environment in relation to the frail state of the older person …). A bridge between hospital and territory is therefore a project that guarantees domestic social and healthcare assistance to the patient with attention on the pre- and post-operative phases, promoting a continuity of care between hospital and home.

Nurses follow the instructions of the surgeon who has performed or is about to perform the operation.

In addition, the nurse performs an integrative role with the general practitioner and possibly with other care professionals such as medical specialists, rehabilitation therapists, nurse’s aides, psychologists, etc. and in any case in synergy with local and hospital services according to the identified needs.

The goal is to make the transition between home, and hospital admission and discharge, as non-traumatic as possible in the delicate phase that often contains steps without assistance, leaving the older patient and his family to fend for themselves.

It is in this context that the Masera Foundation aims to contribute, by facilitating the “handover” among services, to speed up the healing process and to help the older patient stay independent.