Implementation and evaluation of a personalised, integrated and proactive digitally supported care model for older adults with complex clinical needs

Introduction: The growing number of older adults with multimorbidity and complex chronic conditions urgently calls for a transformation of health systems. Fragmented, disease-oriented care supported by poorly integrated information systems undermines both quality and sustainability. Although consensus exists on the need for a personalised, integrated and proactive care model supported by digital tools, its practical implementation remains limited. The absence of a clear operational framework and defined synergies between these components has generated territorial variability and hinders the identification of key factors required to ensure quality care. This study aimed to describe the implementation and evaluation of a multicomponent care model based on these principles, applied in real-world clinical practice across our territory between 2023 and the first half of 2025.

 

Method: ology: The intervention was deployed through the Territorial Geriatrics Service, in coordination with primary care (PC) and the Emergency Department (ED), and systematically applied to all patients managed within geriatric care facilities.

• Personalisation: interviews with patients and/or caregivers identified needs, values and preferences, leading to individualised care plans during admission in any care setting.
• Proactivity: comprehensive geriatric assessment, medication review following the Person-Centred Prescription model, and pre-agreed crisis response plans were implemented. The 3D/D+ tool was used in the ED to detect frailty. Nursing leadership was strengthened through the role of the reference nurse in intermediate care (IC), coordinating with case-management nurses from PC and acute hospitals.
• Digital integration: shared discharge reports, electronic prescribing from IC, and pre-discharge alerts were introduced to ensure continuity of care.

Data were obtained from regional information systems, analysing the population aged >80 years with complex conditions.

 

Results: In the first half of 2025, 100% of discharge reports from IC and 66.7% from the Acute Geriatric Unit included information on complexity identification, agreed care goals, follow-up resources and crisis response level. Medication review appeared in 95.4% of reports, and 90% of recommendations were maintained after three months. The use of IC as an alternative to hospitalisation (step-up) increased: 34.6%(2023), 39.2%(2024) and 44.7%(first half of 2025). Home hospitalisation reached 222 patients (2024) and 106 (first half of 2025). In the ED, 1,477 patients were attended in 2023, 1,584 in 2024 and 967 in the first half of 2025.

 

Conclusion: s: Territorial implementation of the model in real-world practice proved feasible and showed clear improvements in process quality, continuity and coordination of care. In line with international evidence, the most relevant impacts were observed in process quality and care coordination rather than short-term clinical outcomes. These findings highlight the strategic role of IC as a key resource for managing crises among older adults with complex needs, offering an effective and safe alternative to conventional hospitalisation and contributing to system sustainability.

 

Overall, the value of integrated and proactive care models lies in their capacity to align care processes with what matters most to patients, while fostering a professional and organisational culture oriented toward personalisation and prevention. Future work should incorporate patient wellbeing, experience and continuity indicators to better capture the full value of these models.