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This profile is characterised by the presence of complex chronic diseases (CCD) that chiefly affect elderly individuals, who should ideally manage and control these diseases themselves.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In the context of our constantly modernising and updating form of healthcare, we believe that the great ongoing work to optimise care of this type of CCD<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> in acute hospitals, intermediate levels of care and social-medical work should be made public.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Improving the care and possibilities of returning home of hospitalised patients therefore involves restructuring the approach to this process. It is thus indispensable to reunify working strategies in connection with this process, which is often experienced by the patient and their closest circle as very stressful. We therefore believe that it is vitally important to favour coordination between different care levels, amplifying early planning within the hospital for discharge and strengthening the coordination with primary care (PC) centres. All of these aspects are the key factors in patient follow-up to achieve a safe return home.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Given that currently the lines of working in the majority of medical institutions aim to include the viewpoint of personal self-care,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> it has to be underlined that nurses should decide how to include this perspective in the discharge plan, which will help to personalise the preparation of the process. Based on this, the included of contact nurses, case manager nurses (CMN) or discharge transition managers (DTM) is justified. Their titles may vary depending on the context, within the framework of advanced practice nursing (APN), even though they are not usually present in all hospital areas.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Some studies<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> state that successfully managing patients’ discharge from hospital helps to improve the results in terms of their health, reducing the number of readmissions by up to 70% in the case of elderly patients with CCD.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> These interventions show the value of the DTM and similar profiles of PCN, as they play a crucial role in advising patients as well as their families, based on their needs and the interventions that have to be taken into account for their return home.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Although many people say that they receive instructions at the moment of discharge, they also often say that these instruction lack detail, or that they contain a limited amount of information about follow-up actions in case of possible post-discharge problems.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The role of the DTM will increase personalised interventions in the days before discharge, working together with patients and their families on their basic needs by offering health education with nutritional advice, promoting and continuing therapeutic rehabilitation plans and instructions on specific care, while maintaining the continuity of care with PC teams. These strategies will increase the capacity for the early detection and resolution of future situations of instability and exacerbations of chronic processes, etc., thereby reducing their return to health centres and the probability of readmission.</p><p id="par0030" class="elsevierStylePara elsevierViewall">This description has the aim of informing the healthcare system about the benefits that including DTM permanently in hospitalisation areas, at an economic level as well as by reducing readmission rates, while also improving patient quality of life and safety. In the same way, the DTM will also add value to nursing work with a broad range of possibilities in terms of research, while adding another degree of excellence to the profession.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Finally, the future change in generations, with patients who know more about medicine, will involve and demand giving them more information and advice. It will therefore be of key importance for institutions to apply new formulas in terms of person-centred care, and these will have to include the patient and their family when preparing these improvement strategies.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Colominas-Callejas M. Coordinación interniveles y cuidados transicionales: el reto de la cronicidad. Enferm Clin. 2021;31:195–196.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "El cuidado como elemento transversal en la atención a pacientes crónicos complejos" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Rico-Blázquez" 1 => "S. Sánchez Gómez" 2 => "C. 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Journal Information
Vol. 31. Issue 3.
Pages 195-196 (May - June 2021)
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Vol. 31. Issue 3.
Pages 195-196 (May - June 2021)
Letter to the Editor
Coordination between different health-care settings and transitional care: A challenge to take care of chronicity
Coordinación interniveles y cuidados transicionales: el reto de la cronicidad
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