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APPropriate CARE paths for frail elderly patients

Continuity of care

APPCARE model for continuity of care

With regard to continuity of care of frail elderly patients, the main challenges are related to a more sound care coordination, particularly when several echelons are involved in the care process (e.g. primary care, hospital care). This can even be more challenging as a result of the increased role of informal caregivers and the patient’s own network of care. Coordination and communication may then become even more complex. The lack of clear communication among different specialists/healthcare providers treating the same patients for different problems may result in not having completely correct information on medications and/or decision making. This may also affect the follow up of patients after discharge, perceived as poor or even absent and lead to frequent readmissions.

To meet these challenges, the APPCARE model foresees:

  • Benchmark analysis of already existing clinical protocols for the management of chronic patients: In each region, a benchmark analysis will be required to gather all existing resources to be taken into account in the definition of the clinical pathways for patients to follow. This will lead to a repository of good practices for definition of individual clinical plan.
  • Coordination protocol for follow up for each type of discharge
  • Establishment of a case management program for complex patients (homecare assisted).
  • Geriatric follow up of clinical conditions at 1 month and 3 months
  • Clinical pathways for the most common chronic conditions (CVD, COPD, …), in accordance with all involved specialists and the benchmark analysis results.


Registration is open for the APPCARE Final Event to be held in Brussels on May 23rd 2019!

24 April 2019

Registration is open for the APPCARE Final Event to be held in Brussels on May 23rd 2019! For more information, please visit:

Round table “How to integrate project results to promote active and healthy ageing?” call for contribution!

24 April 2019

Round table “How to integrate project results to promote active and healthy ageing?” call for contribution! In the framework of the APPCARE Final Conference, a round table is organized to discuss how findings and recommendations of different projects in the field of Active and Healthy Ageing may be integrated in […]


3 July 2017

On june 9th 2017, the mid-term event of the APPCARE project took place in Valencia in the framework of the Transferring EU public policy into Regional social innovation: improving AHA for a better society workshop. This joint event with representatives of public administrations and experts of different projects working on […]

The APPCARE project will be presented during the 17° AIP (Associazione Italiana di Psicogeriatria) National Congress

6 December 2016

Florence, 30th March–1st April 2017 The symposium “Modalità innovative per la continuità delle cure nell’anziano. Il progetto APPCARE” [“Innovative modalities for the continuity of care in the elderly. The APPCARE project”] will take place on 30th March 2017 at 10 a.m. Click the following link  to consult the up-to-date […]

D 5.1 APPCARE model is now available for consultation!

6 December 2016

Deliverable D4.1 Eu Synthesis Report published

26 November 2015

Issue: November 9, 2015 Marjolein Lugtenberg, Elena Procaccini, Elisa Valia, Choni Doñate, Tamara Alhambra, Francesco Mattace Raso, Rob van Staveren, Carmen Franse, Amy van Grieken, Hein Raat (editors) Erasmus MC – University Medical Center Rotterdam, The Netherlands, Azienda ULSS n.9 Treviso, Italy, Polibienestar, Spain.

The APPCARE project

4 November 2015

APPropriate CARE paths for frail elderly patients – which involves three countries: Italy, Spain and The Netherlands is on line!

European Union

This publication is part of the project / joint action ‘664689 / APPCARE’ which has received funding from the European Union’s Health Programme (2014-2020).

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