PAOLO BOLDRINIPAOLO BOLDRINIDipartimento Interaziendale di Riabilitazione-Dipartimento Interaziendale di Riabilitazione-

LungodegenzaLungodegenzaAzienda ULSS 9 – Ospedale Riabilitativo di Alta Azienda ULSS 9 – Ospedale Riabilitativo di Alta

Specializzazione di Motta di Livenza (TV)Specializzazione di Motta di Livenza (TV)Treviso- ItaliaTreviso- Italia

" Soins et accompagnement à long terme après un traumatisme crânien - analyses critiques "

Vendredi 12 décembre 2008 – Bruxelles (Belgique)

" Long-term care and support after a brain injury – critical analyses "Friday 12 December 2008 - Brussels ( Belgium)

RÉSULTATS DE LA 2ÈME CONFÉRENCE DE CONSENSUS ITALIENNE SUR LA PRISE EN CHARGE À LONG TERME DES ADULTES PRÉSENTANT UNE LÉSION CÉRÉBRALE ACQUISE SÉVÈRE

RESULTS OF THE 2ND ITALIAN CONSENSUS CONFERENCE ON LONG TERM SUPPORT OF ADULTS WITH ACQUIRED BRAIN INJURY

2° NATIONAL 2° NATIONAL CONSENSUS CONSENSUS

CONFERENCE CONFERENCE

Rehabilitation of persons with disability from severe brain injury and their families, after

discharge from the hospital

FINAL REPORT OF THE JURY

Verona june 11°, 2005

SEVERE ACQUIRED BRAIN INJURY (ABI)SEVERE ACQUIRED BRAIN INJURY (ABI)

� Cerebral damageCerebral damage

� Caused by trauma od other factors (hypoxia, Caused by trauma od other factors (hypoxia, CVA, and other) CVA, and other)

� Leading to a coma lasting more than 24 hrs Leading to a coma lasting more than 24 hrs and long lasting sensory and/or motor and/or and long lasting sensory and/or motor and/or cognitive and/or behavioral impairmentscognitive and/or behavioral impairments

� Determining permanent disability Determining permanent disability

CARE PATHWAY OF THE TBI/ABI PATIENT

ACUTE ACUTE PHASE PHASE

EARLY POST ACUTE PHASE

LATE POSTACUTE PHASE

SOCIAL REINSERTION

PHASE

• SURVIVAL

•CLINICAL STABILITY

•PREVENTION OF FURTHER DAMAGES

•FAMILY INFORMATION AND SUPPORT

•MANAGEMENT OF PHYSICAL, COGNITIVE, BEHAVIORAL IMPAIRMENTS • IMPROVEMENT OF INDEPENDENCE (Basic ADL) • FAMILY INFORMATION AND SUPPORT

SOCIAL REINSERTION

•RETURN TO WORK/SCHOOL

• RESTORE QoL

•SUPPORT TO FAMILIES

• CLINICAL STABILITY

• MANAGEMENT OF PHYSICAL, COGNITIVE, BEHAVIORAL IMPAIRMENTS

• IMPROVEMENT OF INDEPENDENCE (Basic ADL)

• FAMILY INFORMATION AND SUPPORT

days weeks months yearsTime frame

Aims

StructuresICU

NEUROSURGICAL WARD

REHAB HOSPITAL/

CENTER

REHAB HOSPITAL/CENTER

OUTPATIENT SERVICES

HOME AND COMMUNITY HEALTH CARE SERVICES

VOCATIONAL PROGRAMS

SHELTERED ACCOMMODATIONS

RESPITE CARE

1°

CONSENSUS CONFERENCE

2000

2°

CONSENSUS CONFERENCE

2005

ORGANIZING COMITTEEORGANIZING COMITTEE

� Italian Society of Physical Medicine and Italian Society of Physical Medicine and Rehabilitation ( SIMFER)Rehabilitation ( SIMFER)

� National Federation of Family Associations National Federation of Family Associations of TBI survivors (Italy)of TBI survivors (Italy)

� Opera Don Calabria, Negrar VR (Italy)Opera Don Calabria, Negrar VR (Italy)

STEERING COMMITTEESTEERING COMMITTEE

Renato Avesani, Renato Avesani, Dipartimento di riabilitazione Opera Don Calabria Dipartimento di riabilitazione Opera Don Calabria Negrar (Verona)Negrar (Verona)

Antonio De Tanti, Antonio De Tanti, Centro Cardinal Ferrari - Fontanellato (Parma)Centro Cardinal Ferrari - Fontanellato (Parma)

Paolo Fogar, Paolo Fogar, Coordinamento Nazionale Associazioni Trauma Coordinamento Nazionale Associazioni Trauma CranicoCranico

Maria Grazia Gambini Maria Grazia Gambini Dipartimento di riabilitazione Opera Don Dipartimento di riabilitazione Opera Don Calabria Negrar (Verona)Calabria Negrar (Verona)

Mariangela Taricco, Mariangela Taricco, UO Recupero e rieducazione funzionale, UO Recupero e rieducazione funzionale, Ospedale Passirana di Rho (Milano)Ospedale Passirana di Rho (Milano)

• HEALTH CARE AND SOCIAL NEEDS

• CARE PATHWAYS

•EPIDEMIOLOGY•REHABILITATION SERVICES•RULES REGULATIONS AND LAWS

•SOCIAL REINSERTION•FAMILY ISSUES•AUTONOMY AND INDEPENDENCE

JURY8 QUESTIONS

Recommendations

WORKING GROUPSWORKING GROUPS

JURYPresident:

Giovanni Apolone, Istituto Mario Negri, Milano (Ita ly)

Members:Wilbert Bakx, Hoensbroeck Rehabilitation Centre, Ho ensroek (The Netherlands)

Paolo Boldrini, Unità Gravi Cerebrolesioni, Dip.di Medicina Riabilitativa, Ferrara (Italy) Ivana Cannoni, Presidente A.Tra.C.To. Firenze (Ital y)

Raffaella Cattelani, Dipartimento di Neuroscienze, Parma (Italy) Carlo Alberto Defanti, Azienda Ospedaliera Niguarda Cà Granda, Milano (Italy)

Francesco Del Zotti, Medico di Medicina Generale, V erona (Italy)Mario Fertonani, Unicredit Banca d’Impresa, Verona( Italy)

Flavia Franzoni, Università di Bologna(Italy)Roberto Gussoni, Ass. Nazionale Imprese Assicuratri ci, Milano(Italy)

Virginio Marchesi, Dipartimento A.S.S.I., A.S.L. Ma genta (Milano) (Italy)Pietrantonio Ricci, Istituto di Med. Legale e delle Assic.ni, Università di Catanzaro(Italy)Gianpietro Rupolo, Direzione Piani e Programmi Soci o-Sanitari,Regione Veneto (Italy)

Stefano Schena, Istituto Don Calabria, Verona(Italy)Jean-Luc Truelle, Service de Neurologie Hospital Fo ch, Paris, (France)

QUESTIONS FOR THE JURYQUESTIONS FOR THE JURY

EPIDEMIOLOGYEPIDEMIOLOGY - - What is the epidemiology of severe acquired What is the epidemiology of severe acquired brain injuries (ABI) in Italy, with reference to the long-term brain injuries (ABI) in Italy, with reference to the long-term residual impairment and disabilities; what is the need for health residual impairment and disabilities; what is the need for health care and social services, for the injured person and his(her) family, care and social services, for the injured person and his(her) family, after discharge from the rehabilitation hospital?after discharge from the rehabilitation hospital?

SERVICES AND INTERVENTIONSSERVICES AND INTERVENTIONS - -What are the most What are the most appropriate rehabilitation interventions ad services for the ABI appropriate rehabilitation interventions ad services for the ABI injured person and his/her family (in terms of effectiveness, injured person and his/her family (in terms of effectiveness, efficiency, and social acceptability ) in the late post-acute phase? efficiency, and social acceptability ) in the late post-acute phase? What are the methods to evaluate the appropriateness? How the What are the methods to evaluate the appropriateness? How the interventions and services should be provided over time?interventions and services should be provided over time?

COORDINATION OF SERVICESCOORDINATION OF SERVICES - - How should the medical and How should the medical and social rehabilitation services be coordinated? Which care pathways social rehabilitation services be coordinated? Which care pathways are more appropriate for the different outcome categories? are more appropriate for the different outcome categories?

QUESTIONS FOR THE JURYQUESTIONS FOR THE JURY

STRUCTURES/FACILITIES -STRUCTURES/FACILITIES - What facilities are required to met the What facilities are required to met the needs of persons with ABI in the late post-acute phase? What needs of persons with ABI in the late post-acute phase? What organization of services is more effective?organization of services is more effective?

RETURN TO WORKRETURN TO WORK What are the most appropriate interventions to What are the most appropriate interventions to facilitate the return to work?facilitate the return to work?

LAWS and REGULATIONSLAWS and REGULATIONS - - What are the relevant strenghts and What are the relevant strenghts and weaknesses of the current laws and regulations concerning the weaknesses of the current laws and regulations concerning the protection and promotion of health and the return to work in persons protection and promotion of health and the return to work in persons with ABI? Does the current welfare system give adequate support to with ABI? Does the current welfare system give adequate support to the person with ABI and his/her family?the person with ABI and his/her family?

QUESTIONS FOR THE QUESTIONS FOR THE JURYJURY

OUTCOME EVALUATIONOUTCOME EVALUATIONOUTCOME EVALUATIONOUTCOME EVALUATIONOUTCOME EVALUATIONOUTCOME EVALUATIONOUTCOME EVALUATIONOUTCOME EVALUATION - - What are the What are the most appropriate methods to evaluate the level of most appropriate methods to evaluate the level of social reinsertion and the quality of life of persons social reinsertion and the quality of life of persons with ABI and their familieswith ABI and their families??

RESEARCH -RESEARCH -RESEARCH -RESEARCH -RESEARCH -RESEARCH -RESEARCH -RESEARCH - What are the main issues to be What are the main issues to be investigated in future researchinvestigated in future research??

EPIDEMIOLOGYEPIDEMIOLOGY

The jury suggests that the epidemiological The jury suggests that the epidemiological knowledge on the consequences of the severe knowledge on the consequences of the severe acquired brain injuries should be improved acquired brain injuries should be improved through the following actions:through the following actions:

● Improving data-gathering and data-Improving data-gathering and data-analysis from the already available clinical analysis from the already available clinical databasesdatabases

● Recording and collecting further Recording and collecting further information in clinical recordsinformation in clinical records

● Developing and implementing “ad hoc” Developing and implementing “ad hoc” national registries and clinical databasesnational registries and clinical databases

INTERVENTIONS, FACILITIES AND CARE INTERVENTIONS, FACILITIES AND CARE PATHWAYSPATHWAYS

IN THE LATE POST-ACUTE PHASEIN THE LATE POST-ACUTE PHASE

� Medical and social rehabilitation interventions should not be Medical and social rehabilitation interventions should not be provided separately; they should be constantly available provided separately; they should be constantly available and coordinated through the whole continuum of care. and coordinated through the whole continuum of care. Medical rehabilitation is essential in the acute and post-Medical rehabilitation is essential in the acute and post-acute phase, but should also be available in the late acute phase, but should also be available in the late phases; on the other hand, social rehabilitation is needed phases; on the other hand, social rehabilitation is needed since the early acute phase, and its relevance should be since the early acute phase, and its relevance should be increased in the following phases; increased in the following phases;

� The long-term interventions for persons with ABI after The long-term interventions for persons with ABI after discharge from the hospital should be based on a network discharge from the hospital should be based on a network involving all the structures and services available in the involving all the structures and services available in the area; a close connection and integration between the area; a close connection and integration between the rehabilitation hospital and the home- and community-based rehabilitation hospital and the home- and community-based services is recommended.services is recommended.

ASSESSMENT OF PERSON’S AND FAMILY’S ASSESSMENT OF PERSON’S AND FAMILY’S NEEDS AND PLANNING OF NEEDS AND PLANNING OF

INTERVENTIONSINTERVENTIONS

� The assessment of persons with severe ABI should be The assessment of persons with severe ABI should be comprehensive, multi-dimensional and multi-disciplinary, comprehensive, multi-dimensional and multi-disciplinary, with active involvement of the person and his/her family, with active involvement of the person and his/her family, and should take into account the clinical, personal and and should take into account the clinical, personal and environmental aspects.environmental aspects.

� The assessment should be carried out on a long term, The assessment should be carried out on a long term, ongoing basis, and should be updated according to the ongoing basis, and should be updated according to the expected changes of the person’s condition and expected changes of the person’s condition and environmental factors.environmental factors.

� Rehabilitation plans should be individualized, by selecting, Rehabilitation plans should be individualized, by selecting, coordinating and integrating appropriate interventions coordinating and integrating appropriate interventions among the different available options. A case-management among the different available options. A case-management approach should be adopted to support the person and approach should be adopted to support the person and his/her family through the care pathwayhis/her family through the care pathway

PROVISION OF REHABILITATION AND PROVISION OF REHABILITATION AND

CARE INTERVENTIONSCARE INTERVENTIONS

� Interventions should be based upon the knowledge and the Interventions should be based upon the knowledge and the

approaches commonly accepted and shared in the scientific approaches commonly accepted and shared in the scientific

and clinical community;and clinical community;

� Interventions should be provided according to an Interventions should be provided according to an

individualized care plan. The plan shoud be defined, individualized care plan. The plan shoud be defined,

developed and verified through a personalized “case developed and verified through a personalized “case

management” approach. management” approach.

� Appropriate information should be provided to the persons Appropriate information should be provided to the persons

with ABI and the family members on an ongoing basis, in with ABI and the family members on an ongoing basis, in

order to explain the aims and goals of interventions and to order to explain the aims and goals of interventions and to

avoid unrealistic expectations about the results of care.avoid unrealistic expectations about the results of care.

PROVISION OF PROVISION OF REHABILITATION AND CAREREHABILITATION AND CARE

THREE CATEGORIES THREE CATEGORIES

OF OUTCOME OF OUTCOME

IN PERSONS WITH SEVERE ABIIN PERSONS WITH SEVERE ABI

� Class 1: VS or MCS Class 1: VS or MCS

� Class 2: Severe disabilityClass 2: Severe disability

� Class 3: Moderate-mild disabilityClass 3: Moderate-mild disability

ASSESSMENT and INTERVENTIONSASSESSMENT and INTERVENTIONSACCORDING TO THE OUCOME CATEGORYACCORDING TO THE OUCOME CATEGORY

FOR EACH OUTCOME CATEGORY, THE ASSESSMENT OFFOR EACH OUTCOME CATEGORY, THE ASSESSMENT OFNEEDS SHOULD BE MADE AT THE LEVEL OF:NEEDS SHOULD BE MADE AT THE LEVEL OF:

� THE PERSONTHE PERSON� HIS/HER FAMILYHIS/HER FAMILY� THE ENVIRONMENTTHE ENVIRONMENT

THE INTERVENTIONS SHOULD ADDRESS THE FOLLOWINGTHE INTERVENTIONS SHOULD ADDRESS THE FOLLOWINGISSUES, WITH DIFFERENT INTENSITY, FOR EACH OUCOME CATEGORY:ISSUES, WITH DIFFERENT INTENSITY, FOR EACH OUCOME CATEGORY:

� Medical careMedical care� RehabilitationRehabilitation� Nursing Nursing � Psychological support Psychological support � EquipmentEquipment� Living EnvironmentLiving Environment� Social life and social relatioships Social life and social relatioships � Financial supportFinancial support� MobilityMobility� Return to work Return to work

ORGANIZATION OF SERVICES•

The organization and coordination of services during the post-acute, post-dischage phase, should be improved; the jury indicated that:

•The classification and denomination of services should be standardized, to facilitate the communication and comparison between centers and programs;

•Database and Registries should be implemented at a local (e.g. heath care district) level;

•Detailed information about the services/resources in a given area should be made available to all the stakeholders ;

ORGANIZATION OF SERVICES

(continued)

� Coordination and integration between medical and social care should be improved through the development of care-pathways and systems of care that should be activated since the early stage.

� Home care programs should be improved, and adequate finacial support should be assured.

� Individual care plans should be developed, fullfilling minimal requirements for persons with ABI.

� Community based, non-residential support programs should be developed, in order to provide respite to family members.

RETURN TO WORK

The jury endorses the following classification of the activities related to the return to work after severe ABI:

•PRE-VOCATIONAL REINSERTION

•SHELTERED EMPLOYMENT

•COMPETITIVE EMPLOYMENT

RETURN TO WORK

THE FOLLOWING RECOMMENDATIONS HAVE BEEN MADE BY TH E JURY:

•Coordination beteween services involved in the diff erent steps of retrurn to work shoud be improved (hospital based occupational programs, community based occupational and vocational services, employm ent services.); • The roles of professionals involved in the vocatio nal reinsertion process should be better specified, and a common language a nd terminology should be shared among them;

•The vocational reinsertion process should be indiv idualizaed and adapted to the specific circumstances and needs

•The feasibility of a vocational-occupational progr am should be evaulated in the arly stages, during the inpatient intensive reh abilitation phase

•The communicaton and relationship beteween the empl oyment services and the companies should be improved, by promoting spe cific information and advice services.

•The network of transitional living facilities for p ersons with ABI should be improved.

FAMILIESFAMILIES

� Improve communication and continuity between hospital-based Improve communication and continuity between hospital-based care and communitiy services care and communitiy services

� The family (and the patient whenever possible) should be The family (and the patient whenever possible) should be informed, trained, and involved in the choice among the different informed, trained, and involved in the choice among the different options of care available in the post-hospital setting.options of care available in the post-hospital setting.

� The Regions should make efforts to increase the local availability The Regions should make efforts to increase the local availability of long term care and rehabilitation facilities;of long term care and rehabilitation facilities;

� A “case management” activity should be provided;A “case management” activity should be provided;� The family should benefit from more effective social supports;The family should benefit from more effective social supports;� Policy makers should promote policies, plans and actions to:Policy makers should promote policies, plans and actions to:

� Simplify and speed-up the administrative procedures to Simplify and speed-up the administrative procedures to obtain the financial and social protection benefits for obtain the financial and social protection benefits for persons witrh disability;persons witrh disability;

� Abolish taxation upon disability-related expenses;Abolish taxation upon disability-related expenses;� Ensure the widespread availability of home based care Ensure the widespread availability of home based care services, according to the current laws and regulationsservices, according to the current laws and regulations

� Ensure adequate financial support for low-income families, Ensure adequate financial support for low-income families, facing particular burden-of-carefacing particular burden-of-care

� Survey studies are needed to gather further data about family Survey studies are needed to gather further data about family issues.issues.

� The cooperation among the family associatons should be improvedThe cooperation among the family associatons should be improved

INFORMATIONINFORMATION

THE JURY ENDORSED THE PROPOSAL FOR A DISTINCTION THE JURY ENDORSED THE PROPOSAL FOR A DISTINCTION BETWEEN TWO BETWEEN TWO

CATEGORIES OF INFORMATION ACITIVITIES CONCERNING CATEGORIES OF INFORMATION ACITIVITIES CONCERNING

THE CONSEQUENCES OF SEVERE ABI:THE CONSEQUENCES OF SEVERE ABI:

� INDIVIDUALIZED INFORMATION ACTIVITIES, addressed to the INDIVIDUALIZED INFORMATION ACTIVITIES, addressed to the

person with ABI, caregivers and other people directly involved in person with ABI, caregivers and other people directly involved in

the specific condition of the person with ABI. The aim of these the specific condition of the person with ABI. The aim of these

information activities is to help the person and all significant information activities is to help the person and all significant

others in dealing with the consequences of the diseaseothers in dealing with the consequences of the disease

� GENERAL INFORMATION ACTIVITIES, addressed to several GENERAL INFORMATION ACTIVITIES, addressed to several

subjects and institutions, aimed at increasing and spreading the subjects and institutions, aimed at increasing and spreading the

knowledge about the consequences of ABI, to support and knowledge about the consequences of ABI, to support and

facilitate the social reinsertion end integration facilitate the social reinsertion end integration

INFORMATIONINFORMATION

RECOMMENDATIONS: RECOMMENDATIONS:

� Structured information programs should be a part of the Structured information programs should be a part of the

individualized care plan of the persons with ABI after the individualized care plan of the persons with ABI after the

discharge from the hospitaldischarge from the hospital

� Specific information activities, including data gathering, Specific information activities, including data gathering,

data analysis and data communication should be developed data analysis and data communication should be developed

and implemented both at a local ( e.g. local community, and implemented both at a local ( e.g. local community,

city) and at a general level (e.g. region, whole countrycity) and at a general level (e.g. region, whole country))

WELFARE SYSTEM AND SEVERE ABIWELFARE SYSTEM AND SEVERE ABIIN ITALY IN ITALY

� ITALIAN NORMS, REGULATIONS AND LAWS RELATED TO ITALIAN NORMS, REGULATIONS AND LAWS RELATED TO THE PROTECTION AND PROMOTION OF HEALTH AND THE THE PROTECTION AND PROMOTION OF HEALTH AND THE RETURN TO WORK IN PERSONS WITH ABI ARE RETURN TO WORK IN PERSONS WITH ABI ARE CONSIDERED TO BE GENERALLY ADEQUATE, WITH TWO CONSIDERED TO BE GENERALLY ADEQUATE, WITH TWO MAIN EXCEPTIONS:MAIN EXCEPTIONS:

� The national laws and regulations concerning the The national laws and regulations concerning the financial supports in the provison of techical aids financial supports in the provison of techical aids and equipment;and equipment;

� A National Act concerning the financial support for A National Act concerning the financial support for persons with disability has not yet been issued, persons with disability has not yet been issued, despite the fact that several proposals have been despite the fact that several proposals have been submitted to the Parliament in the last years submitted to the Parliament in the last years

WELFARE SYSTEM AND SEVERE ABI IN ITALY (continued) WELFARE SYSTEM AND SEVERE ABI IN ITALY (continued)

The jury considers that, despite the fact that rules, laws and The jury considers that, despite the fact that rules, laws and regulations are generally adequate, their actual enforcement regulations are generally adequate, their actual enforcement and effectiveness raises major concerns.and effectiveness raises major concerns.

The jury emphasizes the following critical aspects:The jury emphasizes the following critical aspects:

� The striking differences and discrepancies in the enforcement of The striking differences and discrepancies in the enforcement of laws and regulations in the different regions or areas of the laws and regulations in the different regions or areas of the Country;Country;

� Inadequate connections between the different agencies, Inadequate connections between the different agencies, institutes and services involved in the enforcement of norms institutes and services involved in the enforcement of norms and laws, even when they carry out their activities in the same and laws, even when they carry out their activities in the same area;area;

� Inadequate or inhomogeneous information and knowledge of Inadequate or inhomogeneous information and knowledge of the national and local laws and norms involving the the national and local laws and norms involving the rehabilitation and care of persone with ABI;rehabilitation and care of persone with ABI;

� Inhomogeneous educational backgrounds of the different Inhomogeneous educational backgrounds of the different professionals involved in these issues. professionals involved in these issues.

WELFARE SYSTEM AND SEVERE ABI IN ITALY (continued) WELFARE SYSTEM AND SEVERE ABI IN ITALY (continued)

RECOMMENDATIONSRECOMMENDATIONS

� The denominations and operational definitions utilized in the evaluation, The denominations and operational definitions utilized in the evaluation, planning and implemetation of interventions by the different planning and implemetation of interventions by the different professionals involved in the social renisertion of persons with ABI professionals involved in the social renisertion of persons with ABI should be more consistent;should be more consistent;

� Consistency in the interpretation of laws and regulations should be Consistency in the interpretation of laws and regulations should be improved;improved;

� Communication and coordination between institutes and agencies should Communication and coordination between institutes and agencies should be developed;be developed;

� The current laws concerning the provision of techincal aids and The current laws concerning the provision of techincal aids and equipment through the National Health System should be revised;equipment through the National Health System should be revised;

� The laws and regulation concerning the financial support for persons with The laws and regulation concerning the financial support for persons with disability should be collected in a common framework;disability should be collected in a common framework;

� New approaches to the protection of persons with disability after ABI New approaches to the protection of persons with disability after ABI should be studied, also taking into account the partnership between publi should be studied, also taking into account the partnership between publi and private services, and supplementary allowance programs.and private services, and supplementary allowance programs.

ISSUES TO BE CONSIDERED INISSUES TO BE CONSIDERED IN

FURTHER INITIATIVES: FURTHER INITIATIVES:

� Return to school after ABIReturn to school after ABI

� Specific issues related to socially Specific issues related to socially impaired groups impaired groups

THE FULL TEXT OF THE FINAL THE FULL TEXT OF THE FINAL DOCUMENT IS AVAILABLE IN DOCUMENT IS AVAILABLE IN THESE SITES:THESE SITES:

www.simfer.itwww.simfer.it

www.associazionitraumi.itwww.associazionitraumi.it

www.gcla.itwww.gcla.it

PAOLO BOLDRINIPAOLO BOLDRINIDipartimento Interaziendale di Riabilitazione-Dipartimento Interaziendale di Riabilitazione-

LungodegenzaLungodegenzaAzienda ULSS 9 – Ospedale Riabilitativo di Alta Azienda ULSS 9 – Ospedale Riabilitativo di Alta

Specializzazione di Motta di LivenzaSpecializzazione di Motta di Livenza (TV)(TV)Treviso- ItaliaTreviso- Italia

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