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Interview with Dr. Mario Braga, the new director of the Regional Health Agency of Tuscany region. Previously, at AGENAS, he was the Coordinator of the National Outcomes Programme and of the Welfare Performance Assessment System, responsible for the development and implementation of monitoring and performance assessment systems at national level. He collaborated in the evaluation of hospital and community care models and their sustainability and transferability and was responsible for several research projects on the Health Services at national and international level.

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 Q: Best practices are too often poorly applied or not well known. What are the main obstacles to implementing them? How does AGENAS facilitate the scalability processes of Italian and European Good Practices which have scientific evidence and positive economic impacts towards other Italian regions?

A: The main obstacle to the transfer of good practices, both in Italy and in Europe, is fragmentation. This problem is observed in Italy, in particular, with regard to the organization and management of health systems considering that Italian regions have autonomy in this area.
In fact, there is an excellent level of knowledge on good practices and interventions, among which also experiences have obtained good results. The critical aspect concerns the heterogeneity present at the level of the Italian regions, which does not allow the comparison of experiences on the basis of homogeneous populations, tools and methods of evaluation.
This fragmentation is also evident at the national level with regard to the definition of frailty, for which there is no consensus on a single instrument, not so much at the clinical level, but usable at the management level. This gap makes it difficult to implement a monitoring system at the national level and to promote interventions that are scalable from the local to the national level.
Among the initiatives to overcoming fragmentation, AGENAS for example, has established a table for the implementation of primary interventions concerning the integration of the hospital and the community, with the intention of bringing together professionals, experiences, skills, scientific societies and regions, to define a common ground on which to work. Another initiative to overcome fragmentation is the establishment of a control group formed by selected professionals and relevant decision makers, coordinated by the Ministry of Health, to summarise at national level all the regional experiences on the basis of the national chronicity plan.
An attempt at harmonisation has also been developed with regards to monitoring mechanisms. Some regional initiatives have proposed the transfer of these mechanisms from the hospital level to the intermediate care level, but they involve critical issues at the central level. In fact, the lack of homogeneous evaluation systems and information flows between the various regions, some of which are not even available at national level, does not generate a knowledge of the phenomena at central level.

Q: The ADVANTAGE JA aims to define a European model for combating frailty. Among other aspects there is the adoption of a common definition of frailty and the appropriate tools to detect it. What are the implications for monitoring the prevalence of frailty at national level?

A: The results so far produced by the JA have highlighted and collected good practices and methodologies used at local level. Thinking of extending this knowledge and interventions to the national level, it is necessary to simplify it. If we think, for example, of the detection of frailty, it requires evaluation tools and professionals capable of using them. At the central level, however, only the data flows collected from health facilities are available, which are the hospital discharges, outpatient specialisation, pharmaceuticals and access to A&E. These data allow us to stratify the population on the basis of consumption and use of services, and not on the basis of the level of frailty. For this reason, it is clear that, having to find a definition of frailty that can be used by the central government level, it should be much simpler than the one used by clinicians.
The same applies to integrated models of care, which do not take into account the aspect of frailty, but instead concern the taking charge of the patient and the proactive capacity to intercept and respond to their needs.