This study aims to test a new comprehensive management service package for older adults with two or more chronic conditions (multimorbidity). The package includes digital health tools, personalized guidance, and long-term management support. Researchers will compare the service package with usual care to see whether it reduces hospital readmissions, improves quality of life, and supports daily functioning. About 394 participants will be randomly assigned to either the service package group or the usual care group. Participants will be followed for 6 months to measure health outcomes, treatment adherence, and safety.
Age ≥65 years
Diagnosed with ≥2 chronic diseases or geriatric syndromes (e.g., hypertension, diabetes, frailty, depression)
Willing to provide informed consent
Life expectancy <1 year due to severe illness (e.g., cardiogenic shock)
Currently participating in other clinical trials
Parallel
Service Package Group
Devicepatients receive comprehensive multimorbidity management service package (digital tools, MDT decision support, lifestyle interventions, long-term management tools).
Hospital readmission rate
Hospital readmission rate
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This trial is not recruiting at the moment. You can still explore other options:
