Iglesias-Sierra Virginia, Sánchez-Aguadero Natalia, Recio-Rodríguez José Ignacio, Sánchez-Salgado Benigna, Garcia-Ortiz Luis, Alonso-Domínguez Rosario
Unidad de Investigación de Atención Primaria de Salamanca (APISAL), 37005 Salamanca, Spain.
Instituto de Investigación Biomédica de Salamanca (IBSAL), 37007 Salamanca, Spain.
Nurs Rep. 2025 May 29;15(6):191. doi: 10.3390/nursrep15060191.
The ageing of the population and the progressive increase in chronic diseases represent a major challenge for healthcare systems. The community nurse case manager (CNCM) is emerging as a key figure to provide comprehensive and continued care for complex and pluripathological chronic patients (CPCPs), especially after hospital discharge. The aim of this study is to pilot CNCMs in assisting CPCPs and assess their effects on functional capacity, cognitive performance, quality of life, readmissions, clinical parameters, satisfaction with home care, and caregiver overload. A comparative study will be carried out at two health centres in Salamanca (Spain). In both centres, CPCPs will continue to receive the interventions included in the Castilla y León Health System Portfolio from their primary care (PC) nurses. In the intervention centre, case management provided by a CNCM will be added. We will recruit 212 CPCPs with cardiac or respiratory disease and/or diabetes mellitus who are dependent for basic activities of daily living and have a programmed hospital discharge. An initial assessment will be performed at home after discharge, followed by assessments at 3, 6, and 12 months. The intervention is anticipated to improve all study outcomes. CNCMs may contribute to more proactive and individualised follow-up care for CPCPs and their caregivers, improving care coordination. This study will help to evaluate the feasibility and clinical relevance of incorporating the CNCM's role into PC. This study was registered at ClinicalTrials.gov with the identifier NCT06155591. The date of trial registration was 24 November 2023.
人口老龄化和慢性病的不断增加对医疗保健系统构成了重大挑战。社区护士病例经理（CNCM）正在成为为复杂的多病理慢性病患者（CPCP）提供全面持续护理的关键人物，尤其是在出院后。本研究的目的是试行CNCM协助CPCP，并评估其对功能能力、认知表现、生活质量、再入院率、临床参数、家庭护理满意度和照顾者负担的影响。将在西班牙萨拉曼卡的两个健康中心进行一项对比研究。在两个中心，CPCP将继续从其初级保健（PC）护士那里接受卡斯蒂利亚-莱昂卫生系统组合中包含的干预措施。在干预中心，将增加由CNCM提供的病例管理。我们将招募212名患有心脏或呼吸系统疾病和/或糖尿病、日常生活基本活动需要依赖他人且已安排好出院的CPCP。出院后将在家中进行初始评估，随后在3个月、6个月和12个月时进行评估。预计该干预措施将改善所有研究结果。CNCM可能有助于为CPCP及其照顾者提供更积极主动和个性化的后续护理，改善护理协调。本研究将有助于评估将CNCM的角色纳入初级保健的可行性和临床相关性。本研究已在ClinicalTrials.gov上注册，标识符为NCT06155591。试验注册日期为2023年11月24日。
