隨著台灣即將邁入超高齡社會，高齡者多重慢性病合併老年病症候群已成為臨床照護的嚴峻挑戰。由於高齡者生理儲備力下降，微小壓力源即可引發全身性連鎖反應並導致失能，傳統單一診斷導向的醫療模式已難以滿足複雜的健康照護需求。本文針對專科護理師於目前高齡整合照護政策及流程中的關鍵角色及功能進行討論。首先，於入院早期運用臨床衰弱量表（Clinical Frailty Scale, CFS）或FIND-NEEDS篩檢工具精準辨識高危險群，於初步確認後，啟動周全性老年評估（Comprehensive Geriatric Assessment, CGA）確認非典型症狀。後續照護須將思維由診斷導向轉換為問題導向，融合5Ms架構與SMARTER原則擬定動態照護計畫，並挖掘高齡者價值觀以最在意的事（Matters Most）作為照護決策核心，滾動式動態管理與追蹤病情變化，以少量多次建議提升治療遵從性。最後，以專科護理師領導轉銜照護模式（NP-led transitional care），擔任資訊連結橋樑，確保醫院到社區的照護連續性，以預防再住院。專科護理師能於複雜的高齡者醫療照護需求中尋找秩序，充分發揮評估、溝通、管理與協調的角色，協助醫療團隊與高齡者獲得高品質的整合照護。

As Taiwan rapidly transitions into a super-aged society, the growing prevalence of multimorbidity accompanied by geriatric syndromes among older adults has become a major challenge for clinical practice. Because aging is associated with diminished physiological reserve, even minor stressors may trigger systemic deterioration and functional decline. Consequently, the traditional disease-centered model of care is no longer sufficient to address the complex healthcare needs of this population. This review examines the pivotal role of Nurse Practitioners (NPs) within current integrated geriatric care within current healthcare policies and clinical practice. Early identification of high-risk older adults is achieved through the use of the Clinical Frailty Scale (CFS) and the FIND-NEEDS screening tool, followed by a Comprehensive Geriatric Assessment (CGA) to detect atypical presentations and guide individualized care planning. The article further emphasizes a shift from a diagnosis-oriented to a problem-oriented approach by integrating the 5Ms framework (Mind, Mobility, Medications, Multi-complexity, and Matters Most) with the SMARTER principles to develop dynamic, patient-cen-tered care plans. Eliciting patients’ values and priorities—particularly what matters most to them—serves as the cornerstone of shared decision-making, while continuous monitoring and incremental recommendations help improve treatment adherence. Furthermore, NP-led transitional care facilitates seamless communication and coordination across healthcare settings, ensuring continuity of care from hospital to community and reducing the risk of unplanned readmissions. By integrating comprehen-sive assessment, interdisciplinary communication, care coordination, and longitudinal management, nurse practitioners play a critical role in bringing order to the complexity of caring for older adults with multimorbidity and in delivering high-quality, integrated geriatric care.