Nurse-Led Models of Care for Patients with Complex Chronic Conditions: A Scoping Review

Gordon, Kayleigh; Gray, Carolyn Steele; Dainty, Katie N.; DeLacy, Jane; Seto, Emily

doi:10.12927/cjnl.2019.25972

Cited by 16 publications

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“…There are many studies in the literature about nurse‐led care models in patients with only one chronic condition such as diabetes or chronic obstructive pulmonary disease, but this type of model can be very positive in patients with multimorbidity (Ehrlich et al, 2013). The role of nurses in chronic conditions is often identified as advanced care coordination because patients have complex needs and are complex funding environments; this form of care organisation is a positive opportunity to coordinate the care of patients with complex chronic conditions, such as patients with multimorbidity (Gordon et al, 2019). The multimorbidity focus is on chronic conditions that impact on treatment, functioning, quality of life, morbidity and mortality of patients, so a holistic, patient‐centred approach is more suitable to care for these patients as nurse‐led clinics or nurse‐led interventions (Radner et al, 2014).…”

Section: Discussionmentioning

confidence: 99%

“…Although nurses are integrated in multidisciplinary teams, they seem to be best positioned to effectively provide health education by facilitating learning and advocating for patients and families (Bodenheimer et al, 2005). A recently published scoping review found that nurse‐led care models for patients with complex chronic diseases are primarily led by nurse practitioners (NPs) in Canada and the United States, whereas in the United Kingdom and Australia, these models are led by an advanced clinical nurse (Gordon et al, 2019). No clinical nurse specialist (CNS) model of care was identified in this review, and the authors concluded that there is a need to clarify and refine nurse‐led care models (Gordon et al, 2019).…”

Section: Introductionmentioning

confidence: 99%

“…A recently published scoping review found that nurse‐led care models for patients with complex chronic diseases are primarily led by nurse practitioners (NPs) in Canada and the United States, whereas in the United Kingdom and Australia, these models are led by an advanced clinical nurse (Gordon et al, 2019). No clinical nurse specialist (CNS) model of care was identified in this review, and the authors concluded that there is a need to clarify and refine nurse‐led care models (Gordon et al, 2019). Many definitions of nurse‐led care management are available in the literature.…”

Section: Introductionmentioning

confidence: 99%

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Nurse‐led care management models for patients with multimorbidity in hospital settings: A scoping review

Gonçalves

Mendes

Caldeira

et al. 2022

J Nursing Management

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Aim The aim of this scoping review is to map the nurse‐led care management models for patients with multimorbidity in hospital settings. Background Patients with multimorbidity in hospital, due their complexity, benefit a nurse‐led care management model. This care management model allows for better identification of patients' needs and a person‐centred approach. Evaluation This review followed the JBI methodology for scoping reviews. The search included the international databases Web of Science, CINAHL, MEDLINE, Nursing & Allied Health Collection and grey literature. A total of 21 articles were included in the final content analysis. Key issues Three categories of nurse‐led care management models emerged from the data, namely, nurse‐led programs, case management and nurse facilitator models. The interventions focused on training, discharge support, follow‐up, health promotion and patient‐centred care. Conclusion The centrality of the patient is a common characteristic of nurse‐led care models, namely, the acquisition of disease self‐management skills, preparation for hospital discharge and continuity of care in the community. Implications for nursing management Nurse‐led care management models can empower patients to manage their chronic conditions more effectively. Adapting these care management models in hospital settings will be a challenge for nurse managers. Scoping review protocol The full protocol used can be accessed at doi:.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Nurse‐led care management models for patients with multimorbidity in hospital settings: A scoping review

Gonçalves

Mendes

Caldeira

et al. 2022

J Nursing Management

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“…In a scoping review addressing the management of chronic diseases in Canada, Gordon et al (2019) examined possible approaches to reduce the burden of care. They conclude that managing complex care that meets the needs of patients and providers can be effectively delivered through nurse-led models, including advanced practice models.…”

Section: Live Until You Diementioning

confidence: 99%

Live Until You Die

Nagle

2019

cjnl

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You matter because you are you, and you matter to the end of your life. We will do all we can not only to help you die peacefully, but also to live until you die. " Dame Cicely Saunders Amid the profile of Medical Assistance in Dying (MAID) and a prevailing interest to support living until death, discussions of appropriate care and care settings for dying abound. The when and how of easing the passage from this corporeal being to a state of other being, whatever you believe that to be, has been focal in healthcare discussions in recent years. I remember a time when the notion of "palliative care" was somewhat novel, in later years when a family member was the recipient of excellent end-of-life care, but still many recent instances in which we, "the system" fail to ensure that that final life journey is aligned (as much as possible) with a person's final wishes. Alas, a 2013 survey by the Canadian Institute for Health Information (CIHI) showed that a majority of Canadians preferred to die at home, but few (15%) died outside of a hospital (CIHI 2018).

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“…Several studies have found that nurse-led models enable patients to spend more time with clinicians and coordinate care under a more comprehensive and holistic approach, rather than just a single-disease focus [10][11][12]. Previous studies have also concluded that nurse-led models of care are feasible to deliver comprehensive chronic disease management [10,[12][13][14][15] due in part to the broad scope of nursing practice, holistic approach, and interprofessional team of providers among other factors. A recent study focusing on patients with CCCs demonstrated that nurse practitioner (NP)-led care models provide sufficient quality and competency in diabetes and multimorbidity care [16].…”

Section: Introductionmentioning

confidence: 99%

Experiences of Complex Patients With Telemonitoring in a Nurse-Led Model of Care: Multimethod Feasibility Study

Gordon¹,

Dainty²,

Gray³

et al. 2020

JMIR Nursing

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Background Telemonitoring (TM) interventions have been designed to support care delivery and engage patients in their care at home, but little research exists on TM of complex chronic conditions (CCCs). Given the growing prevalence of complex patients, an evaluation of multi-condition TM is needed to expand TM interventions and tailor opportunities to manage complex chronic care needs. Objective This study aims to evaluate the feasibility and patients’ perceived usefulness of a multi-condition TM platform in a nurse-led model of care. Methods A pragmatic, multimethod feasibility study was conducted with patients with heart failure (HF), hypertension (HTN), and/or diabetes. Patients were asked to take physiological readings at home via a smartphone-based TM app for 6 months. The recommended frequency of taking readings was dependent on the condition, and adherence data were obtained through the TM system database. Patient questionnaires were administered, and patient interviews were conducted at the end of the study. An inductive analysis was performed, and codes were then mapped to the normalization process theory and Implementation Outcomes constructs by Proctor. Results In total, 26 participants were recruited, 17 of whom used the TM app for 6 months. Qualitative interviews were conducted with 14 patients, and 8 patients were interviewed with their informal caregiver present. Patient adherence was high, with patients with HF taking readings on average 76.6% (141/184) of the days they were asked to use the system and patients with diabetes taking readings on average 72% (19/26) of the days. The HTN adherence rate was 55% (29/52) of the days they were asked to use the system. The qualitative findings of the patient experience can be grouped into 4 main themes and 13 subthemes. The main themes were (1) making sense of the purpose of TM, (2) engaging and investing in TM, (3) implementing and adopting TM, and (4) perceived usefulness and the perceived benefits of TM in CCCs. Conclusions Multi-condition TM in nurse-led care was found to be feasible and was perceived as useful. Patients accepted and adopted the technology by demonstrating a moderate to high level of adherence across conditions. These results demonstrate how TM can address the needs of patients with CCCs through virtual TM assessments in a nurse-led care model by supporting patient self-care and keeping patients connected to their clinical team.

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Nurse-Led Models of Care for Patients with Complex Chronic Conditions: A Scoping Review

Cited by 16 publications

References 0 publications

Nurse‐led care management models for patients with multimorbidity in hospital settings: A scoping review

Nurse‐led care management models for patients with multimorbidity in hospital settings: A scoping review

Live Until You Die

Experiences of Complex Patients With Telemonitoring in a Nurse-Led Model of Care: Multimethod Feasibility Study

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