The advanced practice nurse in chronic care as a key element in the integrated care of complex chronic patients

Background: Population ageing and increasing clinical complexity pose major sustainability challenges for health systems (1). Many clinical decompensations could be safely and proactively managed outside hospitals with better care coordination (2).

 

Across Europe, both the European Commission and WHO Europe have promoted integrated care strategies to improve quality, accessibility, and system efficiency (6,7). Strengthening advanced practice nursing roles has been identified as a key component of this strategy (8,9).

In Catalonia, advanced practice nurses (APNs) play an essential role in chronic care by ensuring safe transitions, early detection of decompensations, and specialized home-based care (3). Currently, around 270 nurses hold such roles without formal system recognition (4).

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1. b) Approach

This integrated care model positions the APN at the centre of the care response for complex chronic patients, in line with both regional planning frameworks and European health policy on service integration and professional empowerment (1,6,8).

Key functions include:

• Comprehensive geriatric assessment (VGI-FRAIL) to tailor care intensity to patient frailty levels.
• Proactive follow-up and structured home interventions, guided by shared protocols to anticipate and manage decompensations (2).
• Effective coordination between care levels and multidisciplinary teams, including primary care, community services, and specialist physicians (3).
• Patient and caregiver education to enhance self-management and early symptom recognition (5).
• Nursing-led decision-making for referral to alternative care settings, such as day hospitals or intermediate care units, ensuring safe and planned care.

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1. c) Results

The implementation of this role has demonstrated positive clinical and organisational outcomes, including reduced emergency visits and avoidable admissions, and improved accessibility and patient–caregiver satisfaction (2,5).

This model is highly transferable to other European contexts as it aligns with EU health policy priorities on integrated service delivery, advanced practice roles, and system sustainability (6–9). Evidence from European initiatives—such as the INTEGRATE and ADLIFE projects—shows that nurse-led integrated strategies can improve health outcomes and system efficiency across diverse healthcare structures (7,10).

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1. d) Implications

This model highlights the strategic role of advanced practice nurses in integrated chronic care:

• Improves continuity and safety of care (3).
• Strengthens multidisciplinary collaboration across levels of care.
• Promotes early detection and proactive management, reducing pressure on hospital and emergency services (2).
• Aligns with European health policies aimed at building sustainable, people-centred, integrated systems (6–8).
• Is scalable and exportable to other EU contexts, regardless of organizational structure, consistent with the European Framework for Integrated Health Services Delivery (7,9).