IN VIEW OF THE SUCCESS OF THE TERRITORIAL PATHWAY L’CONTINUIT AGENCY? CARRY OUT AN EARLY TAKE BACK INTO THE PATIENT’S ALERT OR INTERMEDIATE OR REHABILITATIVE CARE FACILITY WHERE THE PERSON IS HOSPITALISED. THE MULTI-DISCIPLINARY INTEGRATED ASSESSMENT TAKES PLACE EITHER DIRECTLY IN THE HOSPITAL OR IN THE INTERMEDIATE CARE BEDS. THE MULTIDISCIPLINARY ASSESSMENT OF NEEDS RESULTS IN AN INDIVIDUALISED CARE PLAN (PAI), WHICH MAKES IT POSSIBLE TO SUPPORT THE GOOD SERVICE PROVIDED FOR HOME RETURNS, WITH APPROPRIATE SUPPORT FOR BOTH THE USER AND THE CAREGIVER.LA WEIGHING THE NEEDS AND ANY MEASURES TO BE TAKEN TO DISCHARGE HAPPENS THROUGH A SPECIFIC ITEM.