Home Health in integrated primary care: current practice and future prospects

Considering the aging population and the growing number of patients with polymorbidity, who are unable of self-care and require control and support, digital technologies with integrated data systems are crucial for comprehensive treatment and accessible high-quality primary care in the era of “remission society.”

We present a clinical case of an older female patient with polymorbidity and frailty as an example of optimized prospective detection and comprehensive management of patients requiring external assistance through information system-based digital integration of primary care with social support organizations. Validated STOPP/START criteria were used for the detection of unreasonably prescribed drug therapies, with the 7 Steps algorithm for therapy optimization. A personalized approach was used to select drug therapy, taking into account the polymorbidity and geriatric status. This included perindopril 5 mg in the morning, bisoprolol 2.5 mg in the morning, torasemide 5 mg in the morning, apixaban 5 mg in the morning and evening, and atorvastatin 20 mg in the evening, with an intermittent topical use of nonsteroidal anti-inflammatory drug-based ointments. The outcomes of comprehensive management were assessed after one year based on the geriatric and physical status, as well as treatment efficacy and tolerability.

The Home Health approach enabled to improve compliance and treatment outcomes, preserve performance status, and increase quality of life and satisfaction with medical care and social support.