Redefining territorial health and social care: the Proactive Multidisciplinary Clinic for frailty

Abstract The Italian National Resilience and Recovery Plan redefined territorial healthcare after Covid-19 pandemic, focusing on structural and procedural innovations in patient management. Emphasis is placed on hospital-community care integration, telemedicine, proactive care for vulnerable populations. These improvements require new models to detect latent needs of the population, often unnoticed. Through epidemiological identification of frail subjects in a Local Health District and the implementation of a multidisciplinary clinic, we developed a targeted sociomedical assessment and proactive intervention model to prevent hospitalization and social isolation. Frail residents of 3 towns of Local Health Unit ASL TO3 were identified considering age > 65 y.o., previous emergency accesses, polypharmacy, chronic conditions, low-income status and disability certification (last 5 years). By September 2024, 697 frail residents without ongoing assistance were identified. By March 2025 we contacted 74 residents; 30 agreed to undergo a frailty assessment from a Family and Community Nurse (IFeC), performed with SUNFRAIL score, Short Portable Mental Status Questionnaire, Instrumental Activities of Daily Living. 28 were further evaluated by a multidisciplinary team (public health doctor, geriatrician, IFeC, GP and social assistant) and 63 proactive interventions were implemented. Medical interventions included geriatric/psychological assessment and deprescribing; social interventions included economic support and activation of voluntary programmes. This project is an example of population health management and community medicine: frail population stratification and multidisciplinary action enabled targeted resource allocation, and reduced healthcare fragmentation through proactive and comprehensive care interventions. This model might represent an effective response to population ageing and increasing healthcare complexity, and can be implemented in other settings facing similar issues. Key messages • Proactive multidisciplinary care can reduce emergency visits and social isolation by identifying sociomedical needs among frail older adults and activating appropriate and targeted care programmes. • New intervention models that combine epidemiological assessment, primary health care, social assistance, specialist services and telemedicine are necessary to redefine frail patients management.