The goal of this clinical trial is to learn if a new comprehensive management service package can help improve health outcomes for older adults who have two or more chronic conditions (multimorbidity). It will also learn about the safety, acceptability, and cost-effectiveness of the service package.
The main questions it aims to answer are:
1. Does the service package lower the number of hospital readmissions in older adults with multimorbidity?
2. Does it improve quality of life, daily function (intrinsic capacity), and treatment adherence?
3. What are the costs and potential risks of using the service package compared to usual care? Researchers will compare the service package to usual care (no service package).
Participants will:
1. Be randomly assigned to either the service package group or the usual care group
2. Use the digital tools and health management support included in the service package (such as apps, monitoring devices, and personalized health guidance)
3. Receive regular follow-up visits and surveys over 6 months to track their health, hospital use, and satisfaction
