131-603 / Advance Nurse Practice in Case Management of patients with complex chronic diseases and high care needs

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
Directorade of Quality, Research, Development and Innovation.


Quality improvement project
Professional learning program on quality and safety
Education in Patient Safety
Human factors
GOP Description
Implementation level
Clinical settings
Primary Care
Hospital Care
– To ensure continuity of care and coordination between the different levels (hospital and community care)
-To ensure interventions that reduce attendance at hospitals and health centers and readmission rate.
– To work in coordination with the social network and community health
– To advise on care within care teams
People included in home care program with clinical complexity; hospitalized with health situations of sudden appearance, assuming change in living conditions and family environment, with advanced chronic pathologies, patients in the end of life situation, lack of self care with inadequate support, caregivers of the target population ..
–    – Definition of Case Management Model in Primary Care and Hospital: Mission, goals, target population, service portfolio …..
–    – Institutional Dissemination.
– Training Plan for Case managers nurses
– Program selection and hiring profiles.
– Definition of “dashboard” to monitor service outcomes
– Adequacy of systems on the Health History
– Practice Accreditation by the Healthcare Quality Agency of Andalusia
– Integration of this practice in the geriatric field, social and health context
Timeframe implementation
One year
Implementation tools available
– Case Management Model Guide published by the Ministry of Health and Welfare.
– Requirements for selection of candidates.
– Basic courses for Case managers nurses
– Professional Accreditation Guide.
– Adequacy of Patient Digital History
Implementation cost
Design guides and its digital publishing: 1,500 euros.
Initial training for 96 nurses: 6,000 euros
Recruitment: 2.016 million euros (Initial: 96 nurses in Andalusia / 8 million inhabitants)
Advanced Practice Accreditation: 0 euros for public health system professionals
Adapting Digital History and information systems: 8,000 to 10,000 euros
Method used to measure the results
Annual evaluation and comparative dashboard between centers.
Research Study multicenter controlled Quasiexperimental: ENMAD.
Professional accreditation level by the ACSA
– Annual dashboard evaluation and BENCHMARKING intercenter
– Research Quasiexperimental, controlled and multicenter Study: ENMAD Study
– Professional accreditation level by the Healthcare Quality Agency of Andalusia
Analysis of the results
Case Management Service:
•Improve patient autonomy for “Immobilized patient” at home and hospital discharges patients.
•Improve the activation of service providers.
•Decrease overload caregiver
•Improve the institutionalization Index in elderly patients
•Improve the management of therapeutic plan for patients and caregivers
•Reduce the number of readmissions and hospitalizations.
Implementation barriers
Did you find implementation barriers?
Please describe implementation barriers
Poor return information through the records in digital history
Describe the strategies used to overcome the barriers (If needed)
Expert Panel created to discuss registration systems and propose amendments. (In process)
Other information
Other information about the GOP that you would like to add (Link or attached document)
The increase in vulnerabilities (old age, chronic illness, comorbidity, frailty …) forces to design strategies to ensure continuity of care in increasingly fragmented systems.

Case management is a collaborative process through which advance practice nurses in the Andalusian Health Service value, plan, implement, coordinate, monitor and evaluate the options and services required to meet the health needs of a person, coordinating communication and available resources to promote results quality and cost-effective.

It is a process to identify problems, design an intervention plan and coordinate activities with professionals and families involved. In this process the nurse case manager sails for the patient to achieve the targets set in their care plan, mobilizing the necessary resources and ensuring a comprehensive and continuous care that meets the needs of the patient and caregiver.

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