Living With Multimorbidity: Care Coordination and Symptom Management Program (COORDINATE)

"The COORDINATE Program is a nurse-led, multicomponent intervention designed to support older adults with multiple chronic conditions during their transition from hospital to home. The intervention is delivered over a 6-week period and includes the following components:~1. Discharge Planning Visit: Conducted in person or via video, this session includes a needs assessment and shared decision-making conversation to identify participants' values and preferences.~2. Question Prompt List: A tailored list of questions is provided to help participants engage more effectively with their care team.~3. Goal Setting: Participants work with a nurse to identify short-term goals and action steps related to their health and care needs.~4. Symptom Monitoring: Participants track symptoms weekly using a symptom checklist to support ongoing management and communication with providers."

Participants in this arm will receive enhanced usual care, which includes standard discharge instructions, scheduled check-ins, and a resource toolkit with educational materials. The content includes guidance on symptom management, advance care planning, and available community resources. Participants will receive follow-up reminders and wellness checks but will not receive the structured, nurse-led intervention provided in the COORDINATE Program.