Comprehensive-Care for Multimorbid Adults Effectiveness Study

"Components of the intervention include:~1. Complete assessment of the patient's and family's needs conducted by the nurse.~2. Comprehensive treatment program developed by the nurse and in consultation with the primary care physician.~3. Multimorbid care plan integrating all care aspects.~4. Action Plan for patients, supporting self management~5. Proactive monitoring according to the plan."