[Nurse Led Care Models in the Context of Community Elders With Chronic Disease Management: A Systematic Review]
BACKGROUND Longer average life expectancies have caused the rapid growth of the elderly as a percentage of Taiwan's population and, as a result of the number of elders with chronic diseases and disability. Providing continuing care services in community settings for elderly with multiple chronic conditions has become an urgent need. PURPOSE To review the nurse led care models that are currently practiced among elders with chronic disease in the community and to further examine the effectiveness and essential components of these models using a systematic review method. METHODS Twelve original articles on chronic disease care planning for the elderly or on nurse led care management interventions that were published between 2000 and 2015 in any of five electronic databases: MEDLINE, PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature) Plus with Full Text, Cochrane Library, and CEPS (Chinese Electronic Periodicals Service)were selected and analyzed systematically. RESULTS Four types of nurse led community care models, including primary healthcare, secondary prevention care, cross boundary models, and case management, were identified. Chronic disease care planning, case management, and disease self management were found to be the essential components of the services that were provided. The care models used systematic processes to conduct assessment, planning, implementation, coordination, and follow up activities as well as to deliver services and to evaluate disease status. The results revealed that providing continuing care services through the nurse led community chronic disease care model and cross boundary model enhanced the ability of the elderly to self manage their chronic diseases, improved healthcare referrals, provided holistic care, and maximized resource utilization efficacy. CONCLUSIONS IMPLICATIONS FOR PRACTICE The present study cross referenced all reviewed articles in terms of target clients, content, intervention, measurements, and outcome indicators. Study results may be referenced in future implementations of nurse led community care models as well as in future research.
Hu li za zhi The journal of nursing