Multimorbidity
Conditions
Keywords
Aged, Patient Navigation., Multimorbidity, Comprehensive Health Care, Geriatric Nursing
Brief summary
This research aims to create and test a tracking (navigation) model to assist in providing care guidance to elderly people (60 years or older) who have two or more chronic diseases at the same time (multimorbidity) immediately after being discharged from the hospital.
Detailed description
A validated and tested navigation protocol applicable to the care of elderly individuals with multimorbidity after hospital discharge will be applied. Implementation of this protocol may demonstrate greater adherence to self-care, improved ability to navigate the healthcare system, and a lower readmission rate among participants. Thus, this research reinforces the strategic role of nursing in care coordination, strengthening evidence-based practices and contributing to health policies focused on healthy aging.
Interventions
BEHAVIORALNavigation for elderly people after hospital discharge.
Patients in the intervention group will be followed for six months through monthly teleconsultations by the doctoral researcher and other nurses with experience in elderly health, as well as nursing students who will be trained and supervised by the researcher to provide standardized care in order to avoid bias.
OTHERRoutine care.
Routine care.
Sponsors
Hospital de Clinicas de Porto Alegre
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
SUPPORTIVE_CARE
Masking
SINGLE (Subject)
Intervention model description
Patients in the intervention group will be followed for six months through monthly teleconsultations by the doctoral researcher and other nurses with experience in elderly health, as well as nursing students who will be trained and supervised by the researcher to provide standardized care in order to avoid bias.
Eligibility
Sex/Gender
ALL
Age
60 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Elderly individuals aged 60 or older; * With confirmed multimorbidity documented in their medical records; * Hospitalized in the SUS (Unified Health System) clinical units (5th North, 6th North, and 7th North), regardless of specialty; * Who will be discharged home; * Have telephone access and have a primary caregiver responsible for assisting with communication, in cases where the elderly person is unable to respond for themselves.
Exclusion criteria
* Elderly people hospitalized in restricted access clinical units (6th south), and those with private insurance or paying out-of-pocket (4th south); * Those transferred to another hospital service or to other institutions; * Patients who are already receiving or will receive navigation care or other safe discharge follow-up care; * Patients in palliative care.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Adherence to self-care | 6 months | Assessed by the Brazilian version of the Self-Care of Chronic Illness Inventory |
Countries
Brazil
Contacts
CONTACTEmily da Silva Eberhardt, Nurse researcher
PRINCIPAL_INVESTIGATORIdiane Rosset, pdh
Federal University of Rio Grande do Sul
Outcome results
None listed