Primary Care Nursing Contributions to Chronic Disease Follow-Up and Continuity of Care
DOI:
https://doi.org/10.22399/ijcesen.4549Keywords:
Primary care nursing, chronic disease management, , continuity of care, patient education, follow-up careAbstract
Primary care nursing plays a pivotal role in managing chronic diseases by providing continuous support and follow-up care to patients. Nurses in primary care settings are often the first point of contact for individuals with chronic conditions, allowing them to develop strong, trusting relationships with patients. This rapport enables nurses to effectively educate patients about their conditions, medication adherence, and lifestyle modifications necessary for disease management. They also conduct regular assessments to monitor disease progression, identify complications early, and coordinate care with other healthcare professionals, ensuring that patients receive comprehensive treatment tailored to their needs. Through consistent communication and follow-up, primary care nurses enhance patient engagement and empower individuals to take an active role in managing their health. Furthermore, the contributions of primary care nursing extend beyond individual patient interactions. By implementing evidence-based practices and standardizing care protocols, nurses contribute to system-wide improvements in chronic disease management. They often participate in interdisciplinary care teams that focus on holistic approaches, addressing not just the physical aspects of disease, but also the emotional and social determinants of health. In addition, primary care nurses play a critical role in the transition of care, particularly when patients move between different healthcare settings, such as hospitals to home care. Their involvement ensures that care continuity is maintained, reducing the risk of readmissions and enhancing overall patient outcomes. Through these efforts, primary care nursing is integral to fostering a healthcare environment that supports long-term health and well-being for patients with chronic diseases.
References
1. Warmelink JC, Wiegers TA, de Cock TP, Klomp T, Hutton EK. Collaboration of midwives in primary care midwifery practices with other maternity care providers. Midwifery. 2017;55:45–52. doi: 10.1016/j.midw.2017.08.010.
2. Jones CD, Vu MB, O’Donnell CM, Anderson ME, Patel S, Wald HL, Coleman EA, DeWalt DA. A Failure to Communicate: A Qualitative Exploration of Care Coordination Between Hospitalists and Primary Care Providers Around Patient Hospitalizations. J Gen Intern Med. 2015;30(4):417–424. doi: 10.1007/s11606-014-3056-x.
3. Barimani M, Vikström A. Successful early postpartum support linked to management, informational, and relational continuity. Midwifery. 2015;31(8):811–817. doi: 10.1016/j.midw.2015.04.009.
4. Bronfenbrenner U. The ecology of human development. Experiments by nature and design. In: Cambridge, Massachusetts: Harvard University Press. 1979.
5. Almeida PF, Santos AM. Primary Health Care: care coordinator in regionalized networks? Rev Saude Publica. 2016;50:80. doi: 10.1590/s1518-8787.2016050006602.
6. Abimbola S, Ogunsina K, Charles-Okoli AN, Negin J, Martiniuk AL, Jan S. Information, regulation and coordination: realist analysis of the efforts of community health committees to limit informal health care providers in Nigeria. Health Econ Rev. 2016;6(1):51. doi: 10.1186/s13561-016-0131-5.
7. Schultz EM, Pineda N, Lonhart J, Davies SM, McDonald KM. A systematic review of the care coordination measurement landscape. BMC Health Serv Res. 2013;13(1):119. doi: 10.1186/1472-6963-13-119.
8. Uijen AA, Schers HJ, Schellevis FG, van den Bosch WJHM. How unique is continuity of care? A review of continuity and related concepts. Fam Pract. 2012;29(3):264–271. doi: 10.1093/fampra/cmr104.
9. Samuelson M, Tedeschi P, Aarendonk D, de la Cuesta C, Groenewegen P. Improving interprofessional collaboration in primary care: position paper of the European Forum for Primary Care. Qual Prim Care. 2012;20(4):303–312.
10. Henize AW, Beck AF, Klein MD, Adams M, Kahn RS. A road map to address the social determinants of health through community collaboration. Pediatrics. 2015;136(4):e993–e1001. doi: 10.1542/peds.2015-0549.
11. Dey RM, De Vries MJW, Bosnic-Anticevich S. Collaboration in chronic care: Unpacking the relationship of pharmacists and general medical practitioners in primary care. Int J Pharm Pract. 2011;19(1):21–29. doi: 10.1111/j.2042-7174.2010.00070.x.
12. da Silva RM, Sobrinho RA, Neves ET, Toso BR, Viera CS. Challenges in the coordination of children's healthcare. Cien Saude Colet. 2015;20(4):1217–1224. doi: 10.1590/1413-81232015204.00742014.
13. Wagner EH, Sandhu N, Coleman K, Phillips KE, Sugarman JR. Improving care coordination in primary care. Med Care. 2014;52(11 Suppl 4):S33–38. doi: 10.1097/MLR.0000000000000197.
14. Valaitis R, Meagher-Stewart D, Martin-Misener R, Wong ST, MacDonald M, O'Mara L, The Strengthening Primary Health Care through Primary C. Public Health Collaboration T Organizational factors influencing successful primary care and public health collaboration. BMC Health Serv Res. 2018;18(1):420. doi: 10.1186/s12913-018-3194-7.
15. Hämel K, Vössing C. The collaboration of general practitioners and nurses in primary care: a comparative analysis of concepts and practices in Slovenia and Spain. Prim Health Care Res Dev. 2017;18(5):492–506. doi: 10.1017/S1463423617000354.
16. D’haenens F, Van Rompaey B, Swinnen E, Dilles T, Beeckman K. The effects of continuity of care on the health of mother and child in the postnatal period: a systematic review. Eur J Public Health. 2020;30(4):749–760. doi: 10.1093/eurpub/ckz082.
17. Pham MT, Rajić A, Greig JD, Sargeant JM, Papadopoulos A, McEwen SA. A scoping review of scoping reviews: advancing the approach and enhancing the consistency. Res Synth Methods. 2014;5(4):371–385. doi: 10.1002/jrsm.1123.
18. Prokop J. Care coordination strategies in reforming health care: a concept analysis. In: Nursing forum: 2016. Michigan: Wiley Online Library; 2016. p. 268–274.
19. Lemetti T, Stolt M, Rickard N, Suhonen R. Collaboration between hospital and primary care nurses: a literature review. Int Nurs Rev. 2015;62(2):248–266. doi: 10.1111/inr.12147.
20. Bahr SJ, Weiss ME. Clarifying model for continuity of care: A concept analysis. Int J Nurs Pract. 2019;25(2):e12704. doi: 10.1111/ijn.12704.
21. Cohen DJ, Balasuhramanian BA, Isaacson NF, Clark EC, Etz RS, Crabtree BF. Coordination of health behavior counseling in primary care. Ann Fam Med. 2011;9:406–415. doi: 10.1370/afm.1245.
22. Javanparast S, Baum F, Freeman T, Ziersch A, Henderson J, Mackean T. Collaborative population health planning between Australian primary health care organisations and local government: lost opportunity. Aust N Z J Public Health. 2019;43(1):68–74. doi: 10.1111/1753-6405.12834.
23. Doessing A, Burau V. Care Coordination of Multimorbidity: A Scoping Study. Journal of Comorbidity. 2015;5(1):15–28. doi: 10.15256/joc.2015.5.39.
24. Gyllstrom E, Gearin K, Nease D, Jr, Bekemeier B, Pratt R. Measuring Local Public Health and Primary Care Collaboration: A Practice-Based Research Approach. J Public Health Manag Pract. 2019;25(4):382–389. doi: 10.1097/PHH.0000000000000809.
25. Briggs J. Systematic Review Resource Package. The Joanna Briggs Institute Method for Systematic Review Research Quick Reference Guide Version. 2015. p. 4.
26. Valentijn PP, Schepman SM, Opheij W, Bruijnzeels MA. Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care. Int J Integr Care. 2013;13:e010. doi: 10.5334/ijic.886.
27. Pawson R, Greenhalgh T, Harvey G, Walshe K. Realist review-a new method of systematic review designed for complex policy interventions. J Health Serv Res Policy. 2005;10(1_suppl):21–34. doi: 10.1258/1355819054308530.
28. World Health Organization . Continuity and coordination of care: a practice brief to support implementation of the WHO Framework on integrated people-centred health services. Geneva: WHO; 2018.
29. Starfield B. Is patient-centered care the same as person-focused care? Perm J. 2011;15(2):63–69. doi: 10.7812/TPP/10-148.
30. Hustoft M, Biringer E, Gjesdal S, Moen VP, Aβmus J, Hetlevik Ø. The effect of team collaboration and continuity of care on health and disability among rehabilitation patients: a longitudinal survey-based study from western Norway. Qual Life Res. 2019;28(10):2773–2785. doi: 10.1007/s11136-019-02216-7.
31. McGowan J, Straus S, Moher D, Langlois EV, O'Brien KK, Horsley T, Aldcroft A, Zarin W, Garitty CM, Hempel S. Reporting scoping reviews—PRISMA ScR extension. J Clin Epidemiol. 2020;123:177–179. doi: 10.1016/j.jclinepi.2020.03.016.
32. van Dongen JJ, Lenzen SA, van Bokhoven MA, Daniëls R, van der Weijden T, Beurskens A. Interprofessional collaboration regarding patients' care plans in primary care: a focus group study into influential factors. BMC Fam Pract. 2016;17(1):10. doi: 10.1186/s12875-016-0456-5.
33. Andrews MM, Storm DS, Burr CK, Aaron E, Hoyt MJ, Statton A, Weber S. Perinatal HIV service coordination: Closing gaps in the HIV care continuum for pregnant women and eliminating perinatal HIV transmission in the United States. Public Health Rep. 2018;133(5):532–542. doi: 10.1177/0033354918789912.
34. Matthys E, Remmen R, Van Bogaert P. An overview of systematic reviews on the collaboration between physicians and nurses and the impact on patient outcomes: what can we learn in primary care? BMC Fam Pract. 2017;18(1):110. doi: 10.1186/s12875-017-0698-x.
35. Wang X, Birch S, Zhu W, Ma H, Embrett M, Meng Q. Coordination of care in the Chinese health care systems: a gap analysis of service delivery from a provider perspective. BMC Health Serv Res. 2016;16(1):571. doi: 10.1186/s12913-016-1813-8.
36. Blumenthal KJ, Chien AT, Singer SJ. Relationship among team dynamics, care coordination and perception of safety culture in primary care. Fam Pract. 2018;35(6):718–723. doi: 10.1093/fampra/cmy029.
37. Veillard J, Cowling K, Bitton A, Ratcliffe H, Kimball M, Barkley S, Mercereau L, Wong E, Taylor C, Hirschhorn LR, et al. Better Measurement for Performance Improvement in Low- and Middle-Income Countries: The Primary Health Care Performance Initiative (PHCPI) Experience of Conceptual Framework Development and Indicator Selection. Milbank Q. 2017;95(4):836–883. doi: 10.1111/1468-0009.12301.
38. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. doi: 10.1191/1478088706qp063oa.
39. Peterson K, Anderson J, Bourne D, Charns MP, Gorin SS, Hynes DM, McDonald KM, Singer SJ, Yano EM. Health Care Coordination Theoretical Frameworks: a Systematic Scoping Review to Increase Their Understanding and Use in Practice. J Gen Intern Med. 2019;34(1):90–98. doi: 10.1007/s11606-019-04966-z.
40. Heaton J, Corden A, Parker G. ‘Continuity of care’: a critical interpretive synthesis of how the concept was elaborated by a national research programme. Int J Integr Care. 2012;12:e12. doi: 10.5334/ijic.794.
41. Clarke R, Bharmal N, Di Capua P, Tseng CH, Mangione CM, Mittman B, Skootsky SA. Innovative approach to patient-centered care coordination in primary care practices. Am J Manag Care. 2015;21(9):623–630.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2024 International Journal of Computational and Experimental Science and Engineering
This work is licensed under a Creative Commons Attribution 4.0 International License.
