A Model for Continuous Care of Fragile Patients

Inclusion criteria: * Adult medically fragile patients with one of the following neurological conditions: mild-to-moderate stroke (Rankin ≤ 3), Multiple Sclerosis (EDSS ≤ 6.5), Parkinson's disease or parkinsonisms, neuromuscular diseases; or orthopedic conditions: femur, pelvis, or humerus fracture. * Able to walk independently, with or without assistive devices. * Adequate cognitive function (MMSE ≥ 24). * Patient or caregiver owns and can use a mobile device with internet/data connection. * Presence of a cognitively capable, cooperative caregiver willing to participate in the study. Exclusion criteria: * Patients with severe neurological or orthopedic conditions who cannot walk independently, even with assistive devices. * Patients with moderate or severe cognitive impairment (MMSE \< 24). * Patients with Barthel Index \> 60. * Patients or caregivers unable to use a mobile device or without internet/data connection. * Patients without a cooperative, cognitively capable caregiver.