This quasi-experimental study aims to assess if a nurse-led proactive intervention can enhance self-care and reduce hospitalizations or accesses to emergency department visits in chronically ill adults over 65 years old. The questions that it seeks to answer are the following: 1. Can a structured, proactive nurse-led intervention reduce hospitalizations and access to emergency departments? 2. Can this intervention improve self-care, medication adherence, and the overall quality of life? To assess its effectiveness, researchers will evaluate health outcomes before and after carrying out the intervention. Participants will receive an initial assessment to identify specific educational needs. To enhance self-care and symptom management, patients will participate in at least three scheduled follow-up sessions (via phone call or face-to-face) during the following six months. They will also complete questionnaires assessing lifestyle quality, medication adherence, and self-care abilities.
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Composite Outcome - access to the emergency department or hospitalization
Timeframe: 6 and 12 months pre-post