GERONTE · Streamlined Geriatric and Oncological evaluation based on IC Technology for holistic patient-oriented healthcare management for older multimorbid patients

Population is aging and the number of complex multimorbid patients to manage will increase sharply. Disease centred approach is not optimal or appropriate to manage this patient group’s inherently complex needs. Change to a patient centred approach will simplify care pathways, secure management and treatment decision- making and decrease healthcare costs. A practical, validated, clinically-appropriate, structured care pathway will be a practical, clinically impactful, and valuable breakthrough for daily practice with multiple impacts that must be quantified. GERONTE multimorbid patient-centred system proposes: 1) Coordination of management by a patient-tailored, interdisciplinary health professional consortium (HPC), including hospital- and home-based professionals, with a case manager; 2) Timely registration of symptoms and patient-reported outcomes at home through anapp for anticipation of avoidable adverse events; 3) Proposal of self-management guidelines according to intrinsic capacity evaluation by geriatrician for patient driven improvement of independent living; 4) Structured collection of data from electronic health records into a dashboard made available to HPC members as well as patient and caregiver, thanks to its capacity to securely interoperate with all electronic health records including software managing medical data. The whole approach will be co-designed with patients, informal caregivers and health professionals. Cancer is an excellent model to develop this approach in multimorbid patients because it is frequent and commonly associated with other morbidities in older patients but also because of its major impact on patients’ general status and coexistent diseases. Cancer already benefits from a multidisciplinary management model that GERONTE will evaluate a care pathway that meets this group’s inherently multidisciplinary and complex care needs, and identify core and critical health and patient preference data to enhance &, strengthen exchange of holistic data, while defining the role of primary care and case management. GERONTE will also provide a comprehensive description of the oncology care pathway for older multimorbid patients across several countries from patient, clinical, organisational, implementation, and economic perspectives and develop country-specific guidelines and best practices for implementation of GERONTE across Europe and for improved management of older multimorbid patients including improved quality of life and independent living at decreased costs.