An increasingly aging population with multiple complex conditions along with budget constraints is putting pressure to several health systems across Europe [1], and the Basque Health Service/Osakidetza is not an exception. Developing new roles for nurses and/or advance nurse practitioners (ANPs) is sought to be a way to increase the efficiency and efficacy of the existing resources and improve health outcomes [2] [3]. Accordingly, the Basque Health Service has set the development of new competences for nurses as one of its key strategic priorities for the period 2013-2016 [4] and several pilot studies have been conducted between 2010 and 2012 [5]. Furthermore, a map with examples from other Regions of Spain and abroad was drafted in order to identify good practices and to adapt them to the Basque context [6]. Three new models of ANPs have been developed, all of which are targeted to people with complex comorbidities who have been previously stratified. First, Hospital Liaison ANPs help hospitalised patients with complex health and social conditions during admission&discharge by coordinating with the Continuity Manager (CM) ANP. In turn, CM ANPs are in charge of coordinating the Care Plan once the patient is in the community and serves as the link with other levels of health and social care. Thirdly, the Case manager ANP delivers advanced and intensive nursing home care
Policy developments: There is consensus among experts assert that the system of social health provision is fragmented, users will be those who suffer the consequences, and that we must provide better coordinated and integrated socio-services model. In Euskadi, with great institutional experience in geriatric care, there is a Basque Council of geriatric care, whose purpose is the guidance and monitoring of policy decisions, regulatory, economic, organizational and care, in terms of care coordination.
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