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.