Development of an integrated care pathway for the prevention and management of biopsychosocial frailty in community-dwelling older adults in Italy: The PDTCP model
Background: With the accelerating demographic transition and rising prevalence of biopsychosocial frailty among older adults, there is a growing need for integrated care models. Italy, among the oldest countries in Europe, faces increasing healthcare costs and a high burden of chronic conditions in...
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| Main Authors: | , , , , , , , , , , , |
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| Format: | Article |
| Language: | English |
| Published: |
Edizioni FS
2025-06-01
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| Series: | Journal of Health and Social Sciences |
| Subjects: | |
| Online Access: | https://journalhss.com/wp-content/uploads/10.192042025DVLP8.pdf |
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| Summary: | Background: With the accelerating demographic transition and rising prevalence of biopsychosocial frailty among older adults, there is a growing need for integrated care models. Italy, among the oldest countries in Europe, faces increasing healthcare costs and a high burden of chronic conditions in the elderly.
Objectives: This study presents a Prevention and Diagnostic Therapeutic Care Pathway (PDTCP) aimed at the early identification and management of biopsychosocial frailty in community-dwelling individuals over 65 years of age.
Methods: The PDTCP is a multidisciplinary model based on multidimensional assessment tools (SFGE and Sunfrail+), enabling risk stratification and tailored interventions. The pathway includes early detection, personalized care planning (PCP), coordination with general practitioners, and structured follow-up. Implementation involves a dedicated governance structure and community engagement initiatives. Outcome indicators include reduced emergency visits, hospitalizations, and institutionalizations.
Results: While currently at the design and implementation phase, the PDTCP targets key performance indicators such as 90% PCP drafting in frail/pre-frail patients, 20% reduction in ER visits, hospitalizations, and falls, and 80% uptake of care plans. A logic model and operational protocol support systematic evaluation.
Conclusions: The PDTCP provides a comprehensive and person-centered framework for managing frailty in aging populations. Further validation through pilot implementations and outcome evaluation is needed to confirm its impact and scalability. |
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| ISSN: | 2499-2240 2499-5886 |