How ASP Ragusa coordinates chronic disease management
across healthcare organisations
ASP Ragusa, the provincial healthcare authority serving the Ragusa area in Sicily, Italy, are now implementing a digital care management solution to support the coordination of care for patients with chronic conditions across organisational boundaries. The solution brings together clinical teams, patient pathways and ongoing care planning, connecting care plans, appointments and clinical follow-up within a shared operational platform.
Care without organisational boundaries
One of the key challenges facing healthcare systems is that responsibility for patient care rarely sits within a single organisation.
Patients with chronic conditions often receive treatment and follow-up from a wide range of healthcare providers throughout their lives, including general practitioners, hospitals, specialist clinics, community healthcare services and regional coordination units. Each organisation contributes to the patient’s care journey, but information, responsibilities and follow-up activities are frequently distributed across different systems and teams.
For healthcare professionals, maintaining a complete overview of a patient’s care plan can therefore be difficult. Appointments, assessments and follow-up activities may be managed by different providers, while responsibility for ensuring that care plans are followed remains a shared effort.
The solution in Ragusa addresses this challenge by creating a shared operational view across healthcare organisations and professional groups. By bringing together care plans, patient lists, appointments, tasks and patient status within a single platform, healthcare professionals can work from the same information and coordinate activities more effectively.
The objective is to support continuous and coordinated care throughout a patient’s lifetime, regardless of where services are delivered. Rather than focusing on individual episodes of treatment, the solution enables healthcare providers to follow the complete patient journey and identify when planned activities or clinical follow-up are at risk of being missed.
This is particularly important for patients living with chronic conditions, where successful outcomes depend on consistent monitoring, timely interventions and collaboration between multiple healthcare providers over many years.
More than a care pathway solution
At the heart of the solution is the DNV Imatis Pathway module, used to design and manage individual patient care plans and clinical pathways. However, the solution extends beyond traditional pathway management. It is designed to support lifelong care management for patients with chronic conditions within a single operational platform.
The aim is not only to document care plans, but also to support healthcare professionals in ensuring patients receive the right follow-up at the right time throughout their care journey.
Supporting proactive follow-up
One of the key aspects of the solution is how patient information, appointments and care plans are brought together to support a more proactive approach to follow-up.
Healthcare professionals and GPs have access to patient-centred worklists that provide an overview of upcoming and completed appointments linked to each patient’s care plan. This creates a single view of patients requiring follow-up and helps coordinate activities across different services.
In addition, we are introducing a care plan compliance calculator. This functionality automatically evaluates planned and completed appointments against the deadlines and milestones defined within each patient’s individual care plan.
Rather than relying on manual reviews, staff will be able to identify patients whose follow-up activities are at risk of falling outside agreed timelines, creating opportunities for earlier intervention, improved adherence to care plans and better continuity of care.
Functionality supporting coordinated care
The solution combines multiple capabilities within a single platform, including:
Digital care pathway management
Ongoing care planning and follow-up
Patient-centred clinical worklists
Appointment tracking across care plans
Care plan compliance and deadline monitoring
Single Sign-On integration
Context launch into external clinical applications, including directly from pathway steps
HL7-based interoperability with existing healthcare systems
Cloud-hosted SaaS delivery
Together, these capabilities support clinical workflows, interoperability and operational coordination across ASP Ragusa’s healthcare environment.
A shared platform across healthcare organisations
This solution shows how a digital platform can move beyond documenting care plans to actively supporting the coordination of patient care across organisational boundaries.
General practitioners, hospital specialists, community healthcare services and regional coordination teams all work from the same patient information, helping improve continuity of care while supporting collaboration throughout the patient’s journey.
ASP Ragusa has already reached an important milestone, with more than 55,000 patients ready to be managed through the solution.
By combining pathways, patient lists, integrations and intelligent follow-up mechanisms, the solution supports healthcare providers in maintaining oversight of complex patient populations while helping ensure care plans are delivered as intended.
From fragmented collaboration to a shared overview
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