The ‘Care for complex chronic patients and advanced chronic patients’ programme has been in place since 2016.
The humanisation of healthcare is a fundamental aspect of the work of the case management nursing team at Manacor Hospital. Its aim is to place the patient and their family at the centre of the care process, taking into account not only their physical but also their emotional and social needs. Since 2016, Manacor Hospital has had a nurse case manager as an integrated part of the ‘Care for complex chronic patients and advanced chronic patients’ programme of the Balearic Islands Health Service.
TDB keeps you informed. Follow us on Facebook, Twitter and Instagram
The nurse case manager programme at Manacor Hospital managed 423 consultations in 2024
The objective of a nurse case manager is to guarantee a comprehensive care plan for the patient, their family and/or their carer using coordination between the different professionals in all areas of care and case management, to ensure continuity of care with the advanced practice of care.
The intervention is aimed at caring for the patients included in the programme, who are broadly speaking patients suffering from two or more chronic pathologies with major organ involvement, patients suffering from only one but with major functional and/or cognitive impairment, patients with palliative care needs and cases of patients in which the care team considers it appropriate.
The activities of a nurse case manager are aimed at promoting comprehensive and continuous care, preventing or improving functional and/or cognitive impairment, facilitating technical aids, promoting the patient’s autonomy, reducing the number of admissions and visits to the emergency services, establishing effective coordination with social devices to solve the problem -especially in those who are highly dependent-, ensuring the established care pathway and guaranteeing continuity of care.
Its main task is to guarantee the patient’s care plan so that they receive care that is appropriate to their needs, avoiding duplication and the negative consequences of fragmented care in the health system. Communication between the different care settings, i.e. between primary care, acute hospitals and intermediate care hospitals, is very important and is achieved through continuity of care.
In recent years, the case management nursing team at Manacor Hospital has increased in number of members, so that there are currently three hospital case management nurses, who participate jointly in the chronicity demands that are generated. Broadly speaking, in order to facilitate the organisation and management of the demands, the approach is made by services. In the last year, 423 requests from healthcare professionals have been recorded.
The team is made up of the following professionals:
Margalida Terrasa Solé, provides support to chronic patients in the trauma, surgery, chronicity and Complex Chronic Patient High-Resolution Consultation units. She also participates in the Humanisation Commission, the Second Victims Working Group, the Patient Participation Group, the Hospital Active Patient Subcommittee and the Emergency Department Chronicity Subcommittee.
Joana M. Julià Mora, is a member of the Hospital Support Team for Palliative Care, which cares for patients with advanced chronic illness and palliative needs and their families; she is also secretary of the Ethics Committee and the Spanish Association of Palliative Care (AECPAL).
Antonia Cuerva Rodríguez, supports the Chronicity, Internal Medicine and Mental Health Unit and participates in the Manacor Mental Health Network. She is also president of the Health and Gender Committee.
These nurse case managers work to create an environment of trust by fostering clear and empathetic communication, including active listening, availability to answer questions and personalisation of care. In addition, their participation in humanisation committees and second victim working groups demonstrates their commitment to continuous improvement in the quality of care.
They play an essential role in ensuring that patients feel valued and respected, which contributes to improving their experience of care and achieving greater emotional well-being in times of vulnerability. Humanisation not only improves the relationship between professionals and patients but can also positively influence the recovery and quality of life of chronically ill patients.