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.
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;
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.
Parallel
Navigation for elderly people after hospital discharge.
BehavioralPatients 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.
Other interventionRoutine care.
Adherence to self-care
Assessed by the Brazilian version of the Self-Care of Chronic Illness Inventory
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This trial is not recruiting at the moment. You can still explore other options:
