Monaldi Arch Chest Dis 2014; 82: 122-152 DOCUMENTO DI CONSENSO Documento preliminare alla definizione degli interventi Minimal Care infermieristici, fisioterapici, dietistici e psicologici attuabili nell’ambito della Cardiologia Riabilitativa e Preventiva First definition of Minimal Care model: the role of nurses, physiotherapists, dietitians and psychologists in preventive and rehabilitative cardiology Ornella Bettinardi 1 (Coordinatore), Letizia da Vico 2 , Antonia Pierobon 3 , Manuela Iannucci 4 , Barbara Maffezzoni 5 , Silvana Borghi 6 , Marina Ferrari 7 , Silvia Brazzo 8 , Antonio Mazza 9 , Marinella Sommaruga 10 , Elisabetta Angelino 11 , Barbara Biffi 12 , Susanna Agostini 13 , Maria Luisa Masini 2 , Marco Ambrosetti 14 , Pompilio Faggiano 15 , Raffaele Griffo 16 1 Psicologo U.O.C. di Emergenza Urgenza Psichiatrica, DSMDP AUSL di Piacenza. 2 Dietista Dipartimento delle Professioni Sanitarie, Azienda Ospedaliero Universitaria Careggi Firenze. 3 Psicologo Servizio di Psicologia, Fondazione Salvatore Maugeri-IRCCS Istituto Scientifico di Montescano (Pavia). 4 Fisioterapista UOD Riabilitazione Cardiologica Presidio Ospedaliero S. Filippo Neri - Presidio Salus Infirmorum Roma. 5 Infermiere Dipartimento di Cardiologia ASL3 Genovese S.S.D. Cardiologia Riabilitativa Degenziale Ospedale “La Colletta” Arenzano (Genova). 6 Infermiere Dipartimento cardiovascolare IRCCS Gruppo MultiMedica Milano. 7 Infermiere Cardiologia Riabilitativa Specialistica, Fondazione Salvatore Maugeri-IRCCS Istituto Scientifico di Montescano (Pavia). 8 Dietista Ambulatorio di Dietetica e Nutrizione Clinica, Fondazione Salvatore Maugeri-IRCCS Istituto Scientifico di Pavia. 9 Fisioterapista U.O. Cardiologia Riabilitativa, Fondazione Salvatore Maugeri-IRCCS Istituto Scientifico di Pavia. 10 Psicologo Area Funzionale di Psicologia Clinica e Supporto Sociale Fondazione Salvatore Maugeri-IRCCS Istituto Scientifico Camaldoli Milano. 11 Psicologo Servizio di Psicologia, Fondazione Salvatore Maugeri-IRCCS Presidio Major Torino. 12 Dietista Servizio di Dietologia e Nutrizione Clinica, Fondazione Don Carlo Gnocchi IRCCS Firenze. 13 Dietista Azienda per l’Assistenza Sanitaria n. 2 Bassa Friulana-Isontina - Ospedale di Gorizia. 14 Cardiologo Cardiologia e Angiologia Riabilitativa, Clinica Le Terrazze Cunardo (Varese). 15 Cardiologo U.O. Cardiologia Ospedali Civili di Brescia. 16 Cardiologo Centro Studi e Formazione GICR-IACPR. Corresponding author: Dr.ssa Ornella Bettinardi: UOC Emergenza Urgenza, Dipartimento Salute Mentale e delle Dipendenze Patologiche, AUSL di Piacenza, Via delle Valli 5, I-29021 Piacenza, Italy; E-mail address: o.bettinardi@ausl.pc.it ABSTRACT: First definition of Minimal Care model: the role of nurses, physiotherapists, dietitians and psychologists in preventive and rehabilitative cardiology. O. Bettinardi (Coordinatore), L. da Vico, A. Pierobon, M. Iannucci, B. Maffezzoni, S. Borghi, M. Ferrari, S. Brazzo, A. Mazza, M. Sommaruga, E.a Angelino, B. Biffi, S. Agostini, M.L. Masini, M. Ambrosetti, P. Faggiano, R. Griffo. Rehabilitative and preventive cardiology (CRP) is con- figured as intervention prevention to “gain health” through a process of multifactorial care that reduces disability and the risk of subsequent cardiovascular events. It makes use of an interdisciplinary team in which every professional needs to have multiple intervention paths because of the different levels of clinical and functional complexity of cardiac pa- tients who currently have access to the rehabilitation. The document refers to the use of interventions by nurses, physiotherapists, dietitians and psychologists that are part of the rehabilitation team of CRP. Interventions of which have been documented, on sci- entific bases and clinical practice, empirical effectiveness and organizational efficiency. The methodological approach of this paper is a first at- tempt to define, through the model of consensus, the mini- mum standards for a CRP evidence based characterized by clearly defined criteria that can be used by operators of CRP. The document describes the activities to be carried out in each of the phases included in the pathways of care by nurses, physiotherapists, dietitians and psychologists. The routes identified were divided, according to the type of patients who have access to the CRP and to the phases of care, including the initial assessment, intervention, evaluation and final reporting, in high medium and low complexity. Examples of models of reporting, used by the operators of the team according to the principles of good clinical practice, are provided. This is made to allow traceability of operations, encourage communication inside the working group and within the patient and the caregiver. Also to give any possible indication for the post-rehabilitation. Keywords: interdisciplinary team, evidence based, care pathways, consensus. Monaldi Arch Chest Dis 2014; 82: 122-152.