Navigation for Elderly People With Multiple Morbidity After Hospital Discharge.

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.

Inclusion criteria

• 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;
• Have telephone access and have a primary caregiver responsible for assisting with communication, in cases where the elderly person is unable to respond for themselves.

Exclusion criteria

• 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.