Background:
As part of the National Recovery and Resilience Plan (NRRP 2021), Mission 6 should provide for the creation of proximity networks, structures of intermediate care and telemedicine in order to improve territorial healthcare: these interventions, regulated by Ministerial Decree 77/2022, will lead to the strengthening and the implementation of Community Houses and Hospitals and to the development of Territorial Operative Centers (COT).

Objective:
COT is an organizational model that performs a function of coordination of taking care of the patient and connection between services and professionists involved in different settings. The role of the COT is to facilitate transition from the hospital to the territory and to reduce the risk of riadmission and improper use of Emergency Department.

Methods:
In the health district of Vignola, COT highlights the importance of building an outlined process for taking care of frail patients on assisted hospital discharges (AHD). The management of this process should consider the peculiarities of territory, which is large and heterogeneous, characterized by both flat areas with high population density and mountainous regions with low population density. COT will be placed inside Vignola’s new Community House. An analysis of indicators related to the hospitalization of frail patients will be performed after the introduction of the COT, in order to evaluate its impact compared to the current model and to verify an improvement on AHD.

Results:
COT’s functions on AHD would include: * receive and decode reports from hospital; * evaluate health needs through multidimensional assessment, identifying the most appropriate program for each patient; * verify the start of the personalised program and monitore its progress over time.

Conclusions:
The originality of this project is to evaluate the role of the COT in the improvement of frail patient’s journey. If the effectiveness were confirmed, this project should be standardize at the provincial level.