Transitional Care 4you (IA)

Posição: Investigadora
Autor: Elisabete Alves
Nome da entidade: Universidade de Évora
Países: França, Portugal

To develop a proposal for a care transition model between the hospital sector and the home (primary health care), based on an individual transnational care plan, in the SUDOE area for people with multimorbidity aged 65 and over and their family carers, by defining functional profiles of older people, based on a cluster of functional, cognitive and social support needs indicators.