In the years that followed, the country’s autonomous communities adapted the national strategy to regional population characteristics and healthcare systems. In Spain, the Estrategia para el Abordaje de la Cronicidad (Strategy for Tackling Chronicity) was published in 2012. Kaiser Permanente has utilised a population stratification process to identify four population groups: (1) the general population, where the focus is on health promotion and disease prevention (2) chronic patients (70–80% of the population), where the focus is on encouraging self-management and self-care support (3) high-risk patients (15%), where the focus is on illness management and (4) highly complex patients (5%), where case management services are prioritised. The PRISMA model focuses on case management and coordinated care provision, connecting different service providers and providing a single access point for the healthcare system. Other initiatives with a similar aim include care models for elderly or frail individuals, such as the Canadian Programme of Research to Integrate Services for Maintenance of Autonomy (PRISMA), which is intended to preserve functional independence among frail elderly people and reduce burnout syndrome among caregivers. The included measures go beyond clinical interventions to encompass health promotion, disease prevention, early screening and detection, case management, rehabilitation, and palliative care. The modified version covers health determinants and a series of coordinated interventions between different healthcare types, levels, and settings. The Chronic Care Model was modified by the World Health Organisation (WHO) in the document Innovative Care for Chronic Conditions, and by other authors in The Expanded Chronic Care Model. The model was developed in 1998 to identify populations at risk of poor outcomes. One of the most well-known models is the Chronic Care Model, which is used around the world. Numerous changes must be made to the way in which healthcare systems are organised to enable the implementation of people-centred chronic care models that deliver satisfactory health outcomes. They require ongoing care and measures to enhance autonomy and provide health education in order to empower families. These conditions incur significant costs for healthcare systems and have a serious impact on the health and quality of life of patients and their caregivers. A total of 20 NIC interventions showed moderately or relatively strong associations for older age groups, higher levels of dependency, and chronic health conditions.Ĭhronic health conditions are common in our society and require adequate care planning. Regarding the presence of certain nursing diagnoses, significant differences were observed by age group, classification of elderly person status, and presence of diseases. Moderately and highly significant differences were observed between dysfunction in physical activity/exercise health pattern and age group, and between dysfunction in other health patterns and classification as a frail or dependent elderly person. The mean number of nursing diagnoses was 7.3 (5.2), NOC outcomes 5.1 (4.1), and NIC interventions 8.1 (6.9). Some 49.2% had one to four health patterns assessed, with more information on biological and functional aspects than on psychosocial aspects. The participants were frequent users of healthcare services, with 12.1% admitted to hospital in the past year. Prevalent conditions included high blood pressure (87.2%), hyperlipidaemia (80%), osteoarthritis (67.8%), and diabetes (56.1%). A total of 57.4% of the participants were women, with a mean age of 73.3 (12.2), and 51% were frail or dependent. The variables were grouped into sociodemographic variables, clinical variables, resources, functional status (health patterns), nursing diagnoses, outcomes, and interventions. With an observational, descriptive, cross-sectional, epidemiological study design, this study was carried out with a sample of 51,374 individuals. The aim of this study was to describe the profile of HCCPs using EHRs from primary care (PC) facilities, presenting patients’ characteristics, functional status based on health patterns, NANDA-I nursing diagnoses, health goals based on Nursing Outcomes Classification (NOC), and care interventions using Nursing Interventions Classification (NIC). The information logged by nurses on electronic health records (EHRs) using standardised nursing languages can help us identify the characteristics of highly complex chronic patients (HCCP) by focusing on care in terms of patients’ health needs.
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