Habitat Microaree in Trieste – A Caring City

The programme is a result of a memorandum of understanding (2006) which was signed by three public entities: the Trieste Local Health Department, the Trieste City Council and the regional Public Housing organisation. The city of Trieste has a population of 204,234 inhabitants characterised by substantial ageing, significant family fragmentation and moderate levels of incoming migrants creating a more diverse population. There is also a high proportion of one-person households, often elderly women.

The Habitat MicroAree is a joint social, health and housing programme aimed at creating an effective and concrete integration between policies and sectors in order to positively influence life contexts, actively involving the local community to reinforce social cohesion. The programme targets the local community living in a ‘micro-area’: a small municipality or housing cluster (500 to 2,500 residents), characterised by a high proportion of public housing, socio-economic vulnerability and a high proportion of over-75 inhabitants.

This approach promotes community development through matching at a ‘micro’ level the demand for services with the available public and/or private resources, thus reinforcing the active participation and resilience of citizens in addressing social and health needs.

Every micro-area has a professional team responsible for contact, activation, coordination of activities (both at individual and community level) and local management of resources.

The programme’s key ingredients for success are that it is:

• local: limited to a specific community context where joint actions take place;
• pluralistic: with multiple actors working together in order to achieve agreed goals;
• comprehensive: as it implements innovation which deals with the whole range of community welfare issues.

The main activities can be divided into:

1. Knowledge Area

• “Door to door” home visits to meet the resident population
• Joint home visits recommended by health and social care services
• Proactive visits to specific population groups

2. Community Development Area

• Socialization activities (informal thematic groups)
• Valuing inhabitants’ skills that are useful to the community (eg. time bank)

3.  Health Intervention Area

• Health monitoring of the most vulnerable (health centre)
• Health literacy and health promotion
• Integration with health and social care services on individual cases.

Each team includes:

• A full time coordinator (a nurse or other professional): acting as a “community health manager”. Their role includes: health promotion, improvement of health and social care integration within individual care pathways, coordination between different services and other professionals, reduction of avoidable hospital admissions
• Two “social concierges”: one social worker from the City Council; one from the Public Housing company, in charge of coordinating community engagement and socialization activities. They are the first to notice residents’ needs and agree on the most appropriate solutions.

Every micro-area has a multi-functional centre with a dual function:

• contributing to the decentralization of health and social care services;
• contributing to the promotion of social cohesion.

Multi functional centres are “local laboratories” where the needs expressed by citizens are combined with the integrated intervention.

Volunteers and resident citizens are also involved in various activities.

Habitat MicroAree’s approach strives to think the neighbourhood in a pluralistic and comprehensive way, with a focus on the most vulnerable residents and social determinants of health. Communities’ health and community development are the main goals. The programme places the person at the centre and promotes participation as a key tool for health prevention and people wellbeing.

Needs are addressed through citizens’ involvement, by the on-going collaboration between different public entities and the third sector.

Protocols are activated in a tiered system: micro, meso, macro that feed into each other.

• At the macro level, the main component is strategy. Representatives of the three entities (the Local Health Department, the City Council and the regional Public Housing organization), meet each semester to designate new “micro-areas” and/or modify contracts. The alliance of the triad became official in 2006.
• At the meso level, the main component is management. A technical group meets to re-assess the organization and programming monthly, and for multi-territorial exchange.
• At the micro level, health and social care interventions are the main components. The integrated professional team meet with residents on a weekly basis to monitor the ongoing interventions.

An example of co-production: the residents participating in social services food programs were first experimentally invited to eat together in common facilities. Under the right conditions, after a ‘start up’ phase, users also became producers (of services). Today many self-organized and self-funded social lunches are held, giving the opportunity to meet, share information, maintain community links or guarantee access to healthy food to specific target groups (e.g. people with chronic diseases).

The effectiveness principles [1] have been developed to guide action in a complex transition and turn Integrated Community Care from aspiration into reality. Each one is a clear and actionable statement that provides guidance for thinking and behaving toward some desired result. Building on the typology (introduced above) and the effectiveness principles, Habitat MicroAree is a practice that can be seen as embodiment of Integrated Community Care.

Habitat MicroAree exemplifies the effectiveness principles:

CO-DEVELP HEALTH AND WELLBEING, ENABLE PARTICIPATION

• Habitat MicroAree promotes active involvement of all community’s actors through a daily presence among the residents and community stakeholders, thus building trust and local alliances. It is a neighbourhood program, for the neighbourhood. All the relevant actors are involved to create networks and, therefore, enact responsibility of institutions.
• The most vulnerable residents are not just “users”: they are at the centre of appropriate and quality care pathways, where they are co-creators of their own health and wellbeing. All aspects of a person’s health and wellbeing are taken into account, through a goal-oriented approach and thanks to the specific mission of the micro area professional team. Thanks to the programmed continuity of care, people living at home are monitored and evaluated regularly applying a person-centred approach.
• The scope of the action is the local dimension, where to implement integration among all the relevant actors and resources, both formal and informal.

BUILD RESILIENT COMMUNITIES

HM builds resilient communities through:

• Self-organization àresidents and community’s stakeholders are involved in a learning process and become managers of community’s places and initiatives
• Place-based/participative approach à a model of co-participation and co-design allows the communities to build on their assets and abilities
• Place development and community building à Creating and valuing community’s places and locations, and offering opportunities to gather and be together in a give-and-take scenario.

Habitat MicroAree provides a stable methodological framework rather than offering performance standards. The availability and continuous presence of HM professional teams in the community and in the daily lives of residents foster mutual knowledge, trust and a self-help movement where resources – both individual and collective – are discovered.

Through teamwork and community groups’ initiative, it is possible to identify creative solutions that overcome the risk of bureaucratic constraints and tackle common issues, breaking the dyad individual – institution.  As a collective, relationships multiply as do resources and the mutual self-help network.  The collaborative context thrives thanks to interviews, a focus on relationship and trust building, and institutions’ availability to answer to neighbourhoods’ needs.

MONITOR EVALUATE AND ADAPT

• At the micro, meso and macro system levels, HM teams meet regularly to monitor and evaluate the program in each territory.
• Residents and community stakeholders participate at the meso and micro levels in evaluating, revising, and adapting the program design.

[1] See TransForm Strategy Paper

The TransForm project developed three main dimensions (drivers, focus and ingredients) that characterise the ICC practices. The assessment of these dimensions is visualised in a slider model that applies to the Habitat Micro Aree. The slider bars illustrate how the various practices of ICC can be positioned on these core dimensions.

Funding is guaranteed by Trieste Local Health Department, Trieste City Council and the regional Public Housing organization. HM has become a permanent part of local services being offered and is financed with ordinary resources (it does not depend on extra/external funding). The total cost is estimated between €100-200.000 per year per site, incl. the professionals dedicated to the programme, the facilities and other resources

Territorial Technical Group: one for each area of intervention, composed of employees/contractors of the services of the three public entities. It is open to the participation of representatives of civil society and of the third sector with the aim of collecting the proposals presented by the territorial area targeted by the programme, in order to design, organise, record and verify the interventions domain of each body and stakeholder involved.

Inter-bodies coordination committee: composed of one representative for each of the three bodies, who identifies the general guidelines and the goals to pursue annually. They meet once every 6 months and/or based on needs.

Over 10 years, the comparison of HM and non HM population (using regional data sources) showed a decreasing ratio of incidence for first hospitalisation, especially when urgent. The decrease of urgent hospitalisation is significant for a number of pathologies: Psychosis –85% for women, –28% for men; Respiratory acute infections –56% for women; Cardiovascular pathology –28% for men (Castriotta et al. 2020).

The program has created useful social capital (relations and interdependencies) by:

• mobilising support mechanisms for the most vulnerable
• involving people in supporting each other
• recognising points of references and increasing the trust in
• “close actors” that are working in the community.

• Continuous presence of the professionals in residents’ daily lives has a positive effect by not being limited only to physical health but considering income, social network, practical needs, daily life and life goals.
• The small-scale approach facilitates real integration, creates conditions for activating citizens and communities
• It also allows the development of services and allocation of resources to counteract the institutionalisation of care (i.e. more personalised and home care)
• The involvement of local communities in innovative solutions to daily problems helps foster more resilient communities

Remaining challenges:

• Keeping the public mandate and direction
• Role and responsibility of professionals (to be activators/not replace missing services)
• Micro-dimensions vs. generalization of practices and learnings
• Learn to work with local resources. Often “scarcity of formal resources” obliges (and allows) you to work with what is already there
• Flexibility to define new standards and models

One of the main goals of the HM Programme has always been to break people isolation and enable them to “go outside” and participate in the community’s life. On the contrary, Covid-19 has made it necessary to make people stay at home, in order to protect their health and the community’s: within this context, and with the regulations imposing social distancing, most of the programme initiatives and actions were almost impossible to implement.

Nevertheless, the professional teams of each micro area maintained their presence in the community, following physical distancing regulations, by: providing active assistance via telephone and video calls; delivering shopping and pharmacy products.  Additionally, active monitoring for highest risk individuals was maintained, proving the effectiveness of knowing well the vulnerabilities of the neighbourhoods.

The multi-functional centers were closed to the public during the peak months. In the more recent months activities have been reprogrammed to contrast isolation (in accordance with safety and hygiene protocols), by forming smaller groups and meeting outdoors.

Relationships are the absolute strength of Habitat MicroAree: thanks to inter-relations amongst people in the community, there is knowledge about residents’ needs and health status (who was most in need, who to call, etc.) and cooperation amongst the residents is fostered. During the emergency, the cohesive networks within each micro area proved valid and resilient: thank to already existing knowledge of vulnerable or hidden vulnerable individuals (those who are unable to reach out for subsidies and services, etc.), it was possible to offer appropriate and timely assistance.

Mutual self-help was reinforced during the lockdown period. Professionals in the community support residents who have learned to help themselves and others, creating a social support network to trust in. A different way of living is created, a sharing of resources, as a reminder that individuals cannot cope on their own.

Professionals’ presence in the community acts as a guarantee of possibilities: it is important to continue to favour the formation and consolidation of groups that work together creating more alliances.

The learning emerging from the experience underlined the need for: higher professional presence in local communities; more social awareness and integration.

A neighbourhood plan for pandemics could aid in decreasing the risk of communities being abandoned and authorities neglecting responsibilities toward vulnerable communities. Residents in the communities could co-participate in creating and developing preparedness strategies.

Castriotta L, Giangreco M, Cogliati-Dezza MG, et al. (2020). Measuring the impact of a social programme on healthcare: a 10-year retrospective cohort study in Trieste, Italy. BMJ Open 2020;10:e036857. p1-9.

WHO Regional Office for Europe. (2019). Habitat-Microareas Programme in Trieste, Italy in Case studies The WHO European Health Equity Status Report Initiative. p52-54.

https://www.euro.who.int/__data/assets/pdf_file/0016/411343/HESRi-case-studies-en.pdf?ua=1

Catalogo di azioni ben descritte rivolte all’equitá.  Centro di Documentazione per la Promozione della Salute, regione Piemonte. https://www.dors.it/CARE/pratiche_completa.php?id=30

Catalogue of well described actions toward equality.  Italy: region of Piedmont, Center for Documentation and Promotion of Health.

Di Monaco R, Pilutti S, d’Errico A, Costa G.  Promoting health equity through social capital in deprived communities: a natural policy experiment in Trieste, Italy. SSM – Population Health, Vol. 12, 2020, https://doi.org/10.1016/j.ssmph.2020.100677

Contact:

Sari Massiotta
Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI)
Direction of Social Services
Tel. +39 040 399 8129 sari.massiotta@asugi.sanita.fvg.it