[Risk factors for one year hospitalization and death of 615 home care patients with multidimensional assessment].

Introduction: The District care activities are often presented as number of patients, interventions or home visits. A better description should render more visible the persons and their clinical problems whose outcomes should be monitored.

Aim: To prospectically monitor the outcomes in a sample of home care patients followed for one year.

Methods: Six hundred sixty two home care patients of two Local Health Units of Veneto Region with at least two nurses visits per month had a multidimensional assessment and were followed for one year.

Results: At the end of follow-up 32% of patients had died, 3.9% had been admitted to a Nursing home; 41.9% had at least one hospital admission and for 49.7% the number of nursing visits was increased. Closeness to death and inadequate family support were independently associated to an increased risk of hospital admission, while patients with severe cognitive impairment tend to be admitted to hospital less frequently. Of the 216 bedridden patients those with inadequate family support are at higher risk for death and hospital admissions.

Conclusions: Home care informative systems allow to assess and monitor the more severe patients thus producing information useful for the continuous improvement of caring processes.