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...
Saved in:
| Main Authors: | , , , , , , , , , , , |
|---|---|
| Format: | Article |
| Language: | English |
| Published: |
Edizioni FS
2025-06-01
|
| Series: | Journal of Health and Social Sciences |
| Subjects: | |
| Online Access: | https://journalhss.com/wp-content/uploads/10.192042025DVLP8.pdf |
| Tags: |
Add Tag
No Tags, Be the first to tag this record!
|
| _version_ | 1849317133470662656 |
|---|---|
| author | Giuseppe LIOTTA Edoardo TREBBI Francesco MONDERA Ferdinando ROMANO Maddalena ILLARIO Michele BISOGNO Edoardo CARNEVALE Michele TREGLIA Igina D’ANTONI Clara DONNOLI Fabio RICCARDI Paola SCARCELLA |
| author_facet | Giuseppe LIOTTA Edoardo TREBBI Francesco MONDERA Ferdinando ROMANO Maddalena ILLARIO Michele BISOGNO Edoardo CARNEVALE Michele TREGLIA Igina D’ANTONI Clara DONNOLI Fabio RICCARDI Paola SCARCELLA |
| author_sort | Giuseppe LIOTTA |
| collection | DOAJ |
| description | 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. |
| format | Article |
| id | doaj-art-2f797e2413f84a879daa052d874e777a |
| institution | Kabale University |
| issn | 2499-2240 2499-5886 |
| language | English |
| publishDate | 2025-06-01 |
| publisher | Edizioni FS |
| record_format | Article |
| series | Journal of Health and Social Sciences |
| spelling | doaj-art-2f797e2413f84a879daa052d874e777a2025-08-20T03:51:19ZengEdizioni FSJournal of Health and Social Sciences2499-22402499-58862025-06-0110223925110.19204/2025/DVLP8Development of an integrated care pathway for the prevention and management of biopsychosocial frailty in community-dwelling older adults in Italy: The PDTCP modelGiuseppe LIOTTA0Edoardo TREBBI1Francesco MONDERA2Ferdinando ROMANO3Maddalena ILLARIO4Michele BISOGNO5Edoardo CARNEVALE6Michele TREGLIA7Igina D’ANTONI8Clara DONNOLI9Fabio RICCARDI10Paola SCARCELLA11Department of Biomedicine and Prevention, University of Rome “Tor Vergata”, Rome, Italy. E-mail: giuseppe.liotta@uniroma2.itPost graduate School of Hygiene and Preventive Medicine, University of Rome “Tor Vergata”, Rome, Italy. E-mail: edoardo.trebbi@uniroma1.itPost graduate School of Hygiene and Preventive Medicine, University of Rome “La Sapienza”, Rome, Italy. E-mail: francesco.mondera@uniroma1.itDepartment of Public Health and Infectious Diseases, University of Rome “La Sapienza”, Rome, Italy. Local Health Unit “Abruzzo 1”, L’Aquila. E-mail: ferdinando.romano@uniroma1.itDepartment of Public Health and infectious Diseases, University of Naples “Federico II°”, Naples, Italy. E-mail: maddalena.illario@unina.itPost graduate School of Hygiene and Preventive Medicine, University of Rome “Tor Vergata”, Rome, Italy. E-mail: michele.bisogno@students.uniroma2.euPost graduate School of Hygiene and Preventive Medicine, University of Rome “Tor Vergata”, Rome, Italy. E-mail: edoardo.carnevale@students.uniroma2.euDepartment of Biomedicine and Prevention, University of Rome “Tor Vergata”, Rome, Italy. E-mail: michele.treglia@uniroma2.itPost graduate School of Hygiene and Preventive Medicine, University of Rome “Tor Vergata”, Rome, Italy. E-mail: igidantoni@libero.itSchool in Nursing Sciences and Public Health, University of Rome “La Sapienza”, Rome, Italy. Email: clara.donnoli@students.uniroma2.euPost graduate School of Hygiene and Preventive Medicine, University of Rome “Tor Vergata”, Rome, Italy. E-mail: fariccardi@hotmail.comDepartment of Human Sciences, University LUMSA – Rome, Italy. E-mail: paola.scarcella@gmail.comBackground: 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.https://journalhss.com/wp-content/uploads/10.192042025DVLP8.pdffrailtyintegrated caremulti-dimensional assessmentolder adultspreventionpersonalized care |
| spellingShingle | Giuseppe LIOTTA Edoardo TREBBI Francesco MONDERA Ferdinando ROMANO Maddalena ILLARIO Michele BISOGNO Edoardo CARNEVALE Michele TREGLIA Igina D’ANTONI Clara DONNOLI Fabio RICCARDI Paola SCARCELLA Development of an integrated care pathway for the prevention and management of biopsychosocial frailty in community-dwelling older adults in Italy: The PDTCP model Journal of Health and Social Sciences frailty integrated care multi-dimensional assessment older adults prevention personalized care |
| title | Development of an integrated care pathway for the prevention and management of biopsychosocial frailty in community-dwelling older adults in Italy: The PDTCP model |
| title_full | Development of an integrated care pathway for the prevention and management of biopsychosocial frailty in community-dwelling older adults in Italy: The PDTCP model |
| title_fullStr | Development of an integrated care pathway for the prevention and management of biopsychosocial frailty in community-dwelling older adults in Italy: The PDTCP model |
| title_full_unstemmed | Development of an integrated care pathway for the prevention and management of biopsychosocial frailty in community-dwelling older adults in Italy: The PDTCP model |
| title_short | Development of an integrated care pathway for the prevention and management of biopsychosocial frailty in community-dwelling older adults in Italy: The PDTCP model |
| title_sort | development of an integrated care pathway for the prevention and management of biopsychosocial frailty in community dwelling older adults in italy the pdtcp model |
| topic | frailty integrated care multi-dimensional assessment older adults prevention personalized care |
| url | https://journalhss.com/wp-content/uploads/10.192042025DVLP8.pdf |
| work_keys_str_mv | AT giuseppeliotta developmentofanintegratedcarepathwayforthepreventionandmanagementofbiopsychosocialfrailtyincommunitydwellingolderadultsinitalythepdtcpmodel AT edoardotrebbi developmentofanintegratedcarepathwayforthepreventionandmanagementofbiopsychosocialfrailtyincommunitydwellingolderadultsinitalythepdtcpmodel AT francescomondera developmentofanintegratedcarepathwayforthepreventionandmanagementofbiopsychosocialfrailtyincommunitydwellingolderadultsinitalythepdtcpmodel AT ferdinandoromano developmentofanintegratedcarepathwayforthepreventionandmanagementofbiopsychosocialfrailtyincommunitydwellingolderadultsinitalythepdtcpmodel AT maddalenaillario developmentofanintegratedcarepathwayforthepreventionandmanagementofbiopsychosocialfrailtyincommunitydwellingolderadultsinitalythepdtcpmodel AT michelebisogno developmentofanintegratedcarepathwayforthepreventionandmanagementofbiopsychosocialfrailtyincommunitydwellingolderadultsinitalythepdtcpmodel AT edoardocarnevale developmentofanintegratedcarepathwayforthepreventionandmanagementofbiopsychosocialfrailtyincommunitydwellingolderadultsinitalythepdtcpmodel AT micheletreglia developmentofanintegratedcarepathwayforthepreventionandmanagementofbiopsychosocialfrailtyincommunitydwellingolderadultsinitalythepdtcpmodel AT iginadantoni developmentofanintegratedcarepathwayforthepreventionandmanagementofbiopsychosocialfrailtyincommunitydwellingolderadultsinitalythepdtcpmodel AT claradonnoli developmentofanintegratedcarepathwayforthepreventionandmanagementofbiopsychosocialfrailtyincommunitydwellingolderadultsinitalythepdtcpmodel AT fabioriccardi developmentofanintegratedcarepathwayforthepreventionandmanagementofbiopsychosocialfrailtyincommunitydwellingolderadultsinitalythepdtcpmodel AT paolascarcella developmentofanintegratedcarepathwayforthepreventionandmanagementofbiopsychosocialfrailtyincommunitydwellingolderadultsinitalythepdtcpmodel |