DOI: 10.5176/2315-4330_WNC17.27

Authors: Marika Lo Monaco, Raffaella Mallaci Bocchio,Giuseppe Natoli, Salvatore Corrao, Francesco Gargano

Objective: Increasingly exacerbations of chronic diseases in frail elderly, causes reduction of patients' quality of life and lead to significant increases in resource utilization and cost to the health care system. A multidimensional and multidisciplinary assessment of an older person allows the identification of the level of stability or fragility of the patient, thereby determining a prognosis and a tailored therapeutic approach. Besides, the revaluation over time allows you to understand the evolution, the critical points of the natural history of the person, tailoring interventions to reduce the risk of disability, hospitalization, and death. The aim of our study is to implement a new approach named M.U.S.E. as improved multidimensional assessment of older outpatients. Methods: the model was developed by a financial support of the Italian Ministry of Health and has been recruiting patients over the age of 65 affected by chronic disease. According to the model, patients are assessed by a doctor and a specialist nurse. If they are affected by one or more of four main chronic diseases (COPD, Hypertension, Hearth Failure, and Diabetes), specific pathways are used to complete the assessment. Long-term outcomes have been investigating. Results and conclusion: the implementation of the M.U.S.E. model of multidimensional assessment seems to improve patients experiences and offer a complete evaluation of comorbidities and nutritional status other than physical and cognitive functionality. The project started in October 2016, and these are preliminary data. The project is in progress.

Keywords: chronical disease; elderly; outpatient; multidimensional; nursing; clinical pathway;


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