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

In an aging society with rising multimorbidity, many patients require ongoing care and support. Digital technologies with integrated data systems are essential for delivering accessible, high-quality primary care in this context. This paper presents the case of an elderly woman with frailty and multiple chronic conditions, demonstrating how proactive care can be optimized through digital integration between primary healthcare and social services. Using the STOPP/START criteria and the 7-step algorithm, a personalized treatment plan was developed. Prior to assessment, the patient used only NSAIDs as needed. Subsequently, she was prescribed perindopril, bisoprolol, torasemide, apixaban, atorvastatin, and topical NSAIDs. Over the course of one year, her geriatric and somatic status, as well as treatment tolerance and effectiveness, were regularly evaluated. The “Home Health” approach improved medication adherence, supported functional status, and enhanced both quality of life and patient satisfaction with integrated medical and social care services. This case highlights the potential of integrated digital systems for managing complex care needs in older adults.