Mariona Espaulella-Ferrer, Felix Jorge Morel-Corona, Mireia Zarco-Martinez, Alba Marty-Perez, Raquel Sola-Palacios, Maria Eugenia Campollo-Duquela, Maricelis Cruz-Grullon, E. Puigoriol-Juvanteny, Marta Otero-Viñas, J. Espaulella-Panicot
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引用次数: 0
Abstract
PurposeOlder people living in nursing homes have complex care needs and frequently need specialists’ advice and support that can be challenging to deliver in a rural setting. The aim of this paper is to describe a model of integrated care in a rural area supported by a nurse case manager.Design/methodology/approachA real-world evidence study of people living in Ribes de Freser nursing home, was conducted between specific timeframes in 2019 and 2022, comparing the casemix and outcomes of a traditional care model with the integrated interdisciplinary model.FindingsThe integrated care model led to a significant reduction in transfers to the emergency department, hospitalisations, outpatient medical visits and a reduction in the number of medicines. In addition, the number of residents receiving end-of-life care at the nursing home showed a substantial increase.Originality/valueThis case study contributes valuable evidence supporting the implementation of an integrated model of nurse case manager support in nursing homes, particularly in the rural contexts, where access to specialist medical staff may be limited. The findings highlight the potential benefits of person-centred integrated care for older adults, addressing their complex needs and improving end-of-life care in nursing home settings.
目的生活在养老院的老年人有复杂的护理需求，经常需要专家的建议和支持，这在农村环境中是具有挑战性的。本文的目的是描述一个模式的综合护理在农村地区由护士个案经理支持。设计/方法/方法在2019年至2022年的特定时间段内，对住在Ribes de Freser养老院的人进行了一项现实世界的证据研究，比较了传统护理模式与跨学科综合模式的病例组合和结果。综合护理模式大大减少了转到急诊科、住院、门诊就诊的人数，并减少了药物的数量。此外，在养老院接受临终关怀的居民人数也大幅增加。独创性/价值本案例研究提供了有价值的证据，支持在养老院，特别是在获得专业医务人员可能有限的农村地区，实施护士病例管理人员支持的综合模式。研究结果强调了以人为本的老年人综合护理的潜在好处，解决了他们的复杂需求，改善了养老院环境中的临终关怀。
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