GerOnTe multimorbid patient-centred system proposes:
1) Coordination of management by a patient-tailored, interdisciplinary health professional consortium (HPC), including hospital- and home-based professionals, with a case manager;
2) Timely registration of symptoms and patient-reported outcomes at home through a web-based app for anticipation of avoidable adverse events;
3) Proposal of self-management guidelines according to intrinsic capacity evaluation by geriatrician for patient-driven improvement of independent living;
4) Structured collection of data from electronic health record into a dashboard made available to HPC members as well as patient and caregiver, thanks to its capacity to securely interoperate with all electronic health records including software managing medical data. The whole approach will be co-designed with patients, informal care givers and health professionals.