Background. Patients admitted to Internal Medicine wards are frequently defined complex patients for
their severe symptoms, comorbidity, disabilities and socioeconomic critical conditions. Once the clinical
stability is achieved, they may be discharged from hospital and to ensure continuity of care they
require personalized arrangements providing medical, nursing and social supports in primary health
care services. The aim of this study is to propose a model of Individual Care Plan (ICP) for complex
patients.
Methods. The model was developed starting from the assessment of multidimensional needs according
to the International Classification of Functioning, Disability and Health (ICF) of World Health Organization
(WHO), and defining for each detected need the goals, the related interventions, the professionals
involved and the devices prescribed for personal use.
Results. This paper presents the model in a practical manner, indicating the ICP of a complex patient.
The ICP, divided into three sections (clinical, care and environmental) describes all the aspects of cure
and care to be delivered in the primary health care services.
Conclusions. The ICP that we proposed is a dynamic tool aimed to ensure the continuity of care and
cure after hospital discharge, to facilitate the communication between hospital and primary health
services and in the different settings of care in which the patient transits, to monitor the evolution
of multidimensional needs over the time. Finally the ICP is useful in evaluating the costs, results and
outcome of care and cure of a patient
