Comprehensive care: a consensus document for integrated, person-centred care pathways

The Health Community Lab (HCL) – Comprehensive care project aimed to define and validate a shared model of comprehensive care for people with severe acquired brain injuries (ABI) and spinal cord injuries, two complex conditions that require an integrated and multidimensional approach. In a context where disability has a profound impact on individual and family life, the project sought to move beyond an exclusively clinical view of rehabilitation, adopting a person-centred and capability-oriented perspective that recognises the person, family and caregivers as active protagonists in the care pathway and their own life project. Through the HCL methodology and the application of the Delphi method, the project involved stakeholders, healthcare professionals, researchers, associations and institutional representatives in a participatory process of co-creation and consensus building. The process was divided into three main phases: preliminary analysis through qualitative interviews, construction of a 73-item questionnaire for the first Delphi round, and final validation of the consensus document. This process resulted in 17 shared statements, 16 of which were fully confirmed by the experts, representing the fundamental principles of comprehensive care. The results highlight the importance of multidisciplinary teams, continuity of care between hospitals, non-profit associations, the community and the home, psychological support for patients and caregivers, therapeutic education, appropriate use of telemedicine, and the promotion of peer support and personalisation of the rehabilitation project. The consensus process made it possible to integrate scientific evidence, professional experience and people's experiences, building a realistic and shared operational framework. The project represents a significant step towards defining common standards of comprehensive care that can be transferred to other chronic disabilities. The results provide a concrete basis for the development of personalised Diagnostic-Therapeutic Care Pathways (PDTA) and for the development of regional policies capable of ensuring equity, quality and continuity of care. The participatory and co-creative approach tested in HCL – Comprehensive care is thus confirmed as an innovative model for healthcare in Tuscany, based on collaboration between institutions, professionals and communities.