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.
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.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
SUPPORTIVE_CARE
Masking
SINGLE
Enrollment
148
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.
Routine care.
Hospital de Clínicas de Porto Alegre
Porto Alegre, Rio Grande do Sul, Brazil
Adherence to self-care
Assessed by the Brazilian version of the Self-Care of Chronic Illness Inventory
Time frame: 6 months
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