Keywords
Frailty
Home Care
Risk Stratification
How to Cite
Abstract
Introduction. Chronic diseases and multimorbidity represent one of the major challenges for healthcare systems worldwide, with significant implications for quality of life, healthcare costs, and organizational sustainability. In Switzerland, approximately 2.2 million people live with at least one chronic condition, and related care accounts for about 80% of national healthcare expenditure. Population ageing and frailty make home care services particularly relevant, as they increasingly manage predominantly older, frail, and multimorbid patients. This study describes the development and testing of a stratification model applied to the population assisted by a public home care service in Canton Ticino.
Objective. The aim was to identify risk and frailty profiles by integrating administrative data and multidimensional assessments, in order to guide personalized and sustainable interventions and support the implementation of proactive care.
Methods. A retrospective, cross-sectional observational study was conducted using a mixed-method convergent parallel design. The proposed model was based on an epidemiological analysis of users cared for in 2018 (aged ≥16 years), through administrative data and Resident Assessment Instrument–Home Care (RAI-HC) evaluations. Variables included age and sex distribution, prevalence of non-communicable diseases (NCDs), multimorbidity, pain, dementia, polypharmacy, and frailty index (FI).
Results. A total of 1572 users were included. The mean age was 79.6 years (SD 13.4), with a predominance of women (73%). Overall, 90.6% presented at least one NCD; cardiovascular diseases were the most frequent (1066 cases), followed by musculoskeletal conditions (696) and cancer (378). Multimorbidity was common: 37% had two NCDs, 16% had three, and 5% had four or more. The most frequent combinations involved cardiovascular and musculoskeletal diseases. Among patients with dementia (n=264), the most frequent comorbidity was cardiovascular–musculoskeletal. The mean number of prescribed medications was eight. The frailty index, calculated from 52 RAI indicators, increased with age and number of NCDs.
Conclusions. The stratification model enabled the characterization of epidemiological, multimorbidity, and frailty profiles within the assisted population, providing evidence to inform proactive care strategies and strengthen clinical and organizational governance in home care. The findings demonstrate the feasibility of using routinely collected data and multidimensional instruments to monitor evolving needs, improve care delivery, and support local healthcare planning.
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