Plateforme territoriale d'appui du Sud-Manche : problématiques de mise en place et étude observationnelle des cas complexes pris en charge

Abstract : Introduction: the Territorial Support Platform (TSP) is a new entity whose role is to support health professionals in the management and coordination of complex care pathways. Objective: determination of implementation issues, and profiles of complex cases supported by the TSP South-Manche. Material and methods: a qualitative study (May 2017-August 2018) using semi-structured individual interviews made it possible to determine the problems of implementation. A second observational study (December 2017-June 2018) aimed to define the profiles of complex cases, their problems and proposed solutions based on the coordination tools used by the platform. Results: the issues highlighted fall into several areas: organization and management of a team, development of informatics and coordination tools, communication with local stakeholders, budgeting, respect for medical confidentiality and human rights, files monitoring. 96 complex cases were supported over a 6-month period. There is a majority of seniors with issues of home care and palliative care, but also younger patients with psychiatric problems or breakage. A city-hospital coordination and the mobilization of many actors of the territory by the operational team is necessary. Conclusion: the TSP of the South-Manche, under the leadership of an experienced multidisciplinary team, is playing a central role in this rural area, to the aging population.
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Master Thesis
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Chloé Tack, Thomas Feillet. Plateforme territoriale d'appui du Sud-Manche : problématiques de mise en place et étude observationnelle des cas complexes pris en charge. Médecine humaine et pathologie. 2018. ⟨dumas-02102157⟩

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