Abstract
Introduction: Aging, increased life expectancy, the presence of chronic diseases, and structural changes in families and society are factors that have an impact on the deterioration of health and the need for a constant increase in health and social resources. In Spain, according to data from the National Institute of Statistics, in 2023, the percentage of the population over 64 years of age was 20.34%, life expectancy was 83 years (80,36 in men and 85,74 in women) and the dependency rate in people over 64 years of age was 31.35%. Chronic diseases are the main cause of dependency and most of these diseases require ongoing monitoring and treatment to prevent dependency from progressing. Decompensations, multiple pathologies and polypharmacy are frequent, which makes care management difficult and requires the activation of more social resources.
Methodology: Following the recommendations of the Strategy for Addressing Chronicity in the National Health System, in the Balearic Islands, in 2017, a new proactive and coordinated care model was implemented for addressing complex and advanced chronic patients, which involves structural changes at the different levels of care, and focuses on person-centred care and support for their caregivers and where the case management nurse (CMN) has a key role in ensuring continuity of care and coordination between the different care areas. The main objective of the CMN is to ensure comprehensive and quality care through the coordination of all the agents involved, ensuring continuity of care, with a collaborative, comprehensive and multi-professional advanced practice model that promotes that the person can be at home most of the time, with the best quality of life.
Results: There are currently a total of 71 CMNs in the Balearic Islands, 53 of them in primary care, 14 in acute care hospitals and 4 in intermediate care hospitals. Among other interventions, the CMNs promote the proactive identification of patients with complex and advanced chronicity (with palliative care needs) and high dependency and record it in the information systems, proactive home care, manage admissions to the most appropriate resource, plan discharge together with the healthcare team, manage appointments for continued care with their primary care nurse, make indications for medical products and technical aids, promote effective coordination between different professionals from different healthcare areas and other institutions (such as social services and education), joint work with social workers, and carry out training actions for patients, families and other professionals. The number of people identified with complex chronicity in October 2024 is 29.499 (79.34% over those expected) and with advanced chronicity 1.971 (15.90% over those expected).
Conclusions: Patients with chronic diseases require comprehensive and integrated care that responds to the multiple complexes needs they present. Proactive identification of the population, activation and adaptation of health and social resources, shared information systems together with professionals who ensure continuity of care such as CMN are interventions that improve the quality of care for these people.