1. Introduction
In the last few decades, the impact of chronic health conditions on health systems, as well as on quality of life, frailty, and dependence of those affected, has been brought to light. Chronic diseases, such as heart failure, high blood pressure, hyperlipidemia, and diabetes, are long-term, slow-progressing health problems that have an impact on quality of life for both patients and their caregivers. Consequently, care models should be able to properly address the problems brought about by chronic conditions. Care models have been developed that are aimed at age and frailty, such as the Chronic Care Model (CCM) [
1], the Program of Research to Integrate Services for Maintenance of Autonomy (PRISMA) [
2], and Kaiser Permanente (KP) [
3].
According to the 2017 Spanish National Health Survey (ENS), 22.8% of the population reports having a chronic limitation when carrying out their daily activities, with 4.3% having severe limitations [
4]. In the Autonomous Community of the Canary Islands (ACCI), an estimated 6% of people over 16 years old are severely limited when carrying out their daily activities due to suffering from some kind of health condition [
5].
The
Estrategia para el Abordaje de la Cronicidad [Strategy for Tackling Chronicity] (EAC) of the Spanish National Health System (SNHS) highlights the need to stratify the population in order to predict the needs of those suffering from chronic conditions. This stratification is linked to a comprehensive assessment of patients’ medical, care, functional, and social needs [
6].
There are multiple population groups for the stratification of chronic patients, e.g., adjusted morbidity groups (AMGs), clinical risk groups (CRGs) [
7], and adjusted clinical groups (ACGs) [
8]. A project to stratify the Spanish population was carried out by AMG in the SNHS, providing a multi-level tool, which complies with predefined profiles for each level according to a series of health and social care variables, and developing a risk prediction model [
9].
The AMG is a stratification tool that has been proven useful and fit-for-purpose, just like the other existing groups [
10]. This stratification follows the Kaiser pyramid model, which establishes percentiles on the basis of complexity levels [
3]. In this way, we established four population complexity levels: (1) population without chronic conditions; (2) low-risk chronic population, i.e., people whose individual complexity value is lower than the 80th percentile of the chronic condition population; (3) moderate-risk chronic population, i.e., people whose individual complexity value is in the 80–95th percentile of the chronic condition population; (4) high-risk chronic population, i.e., people whose individual complexity value is higher than the 95th percentile of the chronic condition population.
As indicated in the EAC in the ACCI, highly complex chronic patients (HCCPs) make up around 5% of the population. These patients require a case management approach to care: personalized care according to their needs to optimize the coordination of system resources, improve the quality of life of patients and caregivers, and avoid emergency admissions and hospitalizations [
6].
Primary care (PC) is at the core of complex chronic patient care. Community nurses can identify individual, family, environmental, and community care needs. Keeping in mind the changes that have taken place in the last few decades regarding population structure, with increasing degrees of frailty, dependence, and chronic conditions, nurse identification of care needs should contribute to better individual care for the HCCP. Furthermore, this should be taken into consideration when deciding health and resource management policies. On that note, in their assessment report and priority guidelines, the EAC once again highlighted the importance of community nurses in this type of patient care, underlining the need to develop the role of these professionals regarding individuals with chronic conditions, thereby promoting the application of comprehensive care assessments [
11].
The current total population of the Autonomous Community of Canary Islands is 2.207 million people. PC professionals in the Canary Islands have maintained electronic health records (EHRs) since 2010. Here, they have access to HCCP stratification information, the AMG color (indicating complexity), and the diagnostic descriptive labels used for the over-14 age group. Additionally, the professional team regularly reviews all the available information and can, according to the criteria, actively include patients in the HCCP program using information from the AMG, and other clinical variables: the Barthel index, Pfeiffer’s test, polypharmacy, admissions, etc.
Community nurses have access to a specific module in the EHR in order to log the care they provide. This module follows nursing process logic [
12]. The nurse creates a care plan by starting with an assessment based on Marjory Gordon’s health patterns (HPs) [
13]. This assessment explores the individual’s functional status in depth using 11 HPs: health perception/health management; nutrition/metabolism; elimination; physical activity/exercise; sleep/rest; cognition/perception; self-perception/self-concept; role/relationships; sexuality/reproduction; coping/stress tolerance; values/beliefs. The assessment of each HP is with the help of complimentary measuring instruments such as scales, tests, and questionnaires. After completing the assessment, the professional should give their clinical judgement and record the functional status result of each HP as normal, altered, risk of alteration, or nonassessable.
In order to identify and diagnose individual care needs, as well as plan their care, nurses use the NANDA-I standardized taxonomy [
14], the health outcomes section of the Nursing Outcomes Classification (NOC) [
15], and the care interventions section of the Nursing Interventions Classification (NIC) [
16]. In Spain, the use of standardized nursing languages (SNLs) is regulated by the Royal Decree 1093/2010 of 3 September and is part of the minimum dataset in clinical reports category of the SNHS [
17].
The aim of this study is to use the NANDA-I classification system and the SNLs to describe the population care needs of HCCPs in the Canary Islands and analyze how they relate to other sociodemographic and clinical variables, such as frailty and dependence levels.
4. Discussion
The most prevalent characteristics of the HCCP are well identified in the literature. Within these characteristics is the presence of comorbidities, increased use of emergency services, several hospitalizations per year, loss of personal independence, polypharmacy, and the presence of certain illnesses such as HF or COPD [
25]. The classification of patients using the AMG is useful in planning care, but it is necessary to continue improving the quality of available information in the EHR so that it can be used in the stratification system. This is demonstrated by the large variability in healthcare costs for users in similar complexity percentiles [
26]. In this respect, the weight of care needs identified through NDs has not been sufficiently researched or assessed for these types of patients.
Nurse identification of care needs contributes to the improvement of personalized care of the HCCP can and should help inform health policies and manage resources in epidemiological nursing. NDs can be used as key descriptors of population care needs for the profile under study, especially in more complex cases. A systematic exercise of epidemiological nursing allows for the creation of sentinel networks for care needs [
27]. Furthermore, the inclusion of these needs in the EHR and in the stratification algorithms can improve predictions about degrees of complexity [
28], as well as elevate the explanatory power of the use of healthcare resources [
29].
In our context (PC in the Canary Islands within the public SNHS), several studies have addressed and discussed the care needs identified for specific groups of patients. This is especially true in relation to psychosocial issues such as loss and mourning [
30,
31], for frail and dependent patients in particular, with characteristics similar to the population in this study [
32].
It is widely known that nurses often record fewer activities than what they actually perform [
33]. Traditionally, nursing documentation has consisted of narrative notes that are often long, ambiguous, and redundant [
34]. In terms of the use of NDs in the EHR, the tendency of nurses to only record diagnostic labels has been highlighted, making the total of said records very high in number [
35]. Therefore, with regard to the functional status assessment using HPs, it should be highlighted that information is recorded in more than 84% of HCCPs. To put these data into context, according to a report released in July 2022 on the use of the EHR in the Canary Islands, only 27% of the adult population had an HP assessment in their records. As such, for HCCPs, nurses record a great deal more information in the area of standardized HPs. This study’s results are consistent with previously reported studies, which identified the most assessed HP is health perception/health management [
36].
Three diagnostic labels were identified in one in every four patients: readiness for enhanced health management, impaired skin integrity, and risk for falls. The identification of these problems should help with managing HCCP care.
The high prevalence of the first of these diagnoses, corresponding to the domain of health promotion and self-management, i.e., readiness for enhanced health self-management, is common in the EHR. As stated in its definition, in the most recent NANDA-I classification of NDs, this label is used to indicate that the person has ‘a pattern of satisfactory management of symptoms, treatment regimen, physical, psychosocial, and spiritual consequences with lifestyle changes inherent in living with a chronic condition, which can be strengthened’ [
15]. Women, under-80s, and nondependent persons present this ND very frequently, giving the patient an active role in the planning and provision of their care.
There are no previous studies that estimated the prevalence of impaired skin integrity in the HCCP within our context. However, the most appropriate comparison framework for this study’s findings could be the study on the prevalence of pressure injuries and other skin lesions related to dependence in Spanish PC facilities, performed in 2017 [
37]. This investigation, led by the Spanish National Advisory Group for the Study of Pressure Ulcers and Chronic Wounds (GNEAUPP), found that the prevalence of pressure injuries and other skin lesions related to the dependence of over-65 s was 0.3%, while, in people who are part of home care programs, it was 6%. These results are considerably lower than the results of our study. In our investigation, prevalence varied on the basis of whether the person was independent (41%), frail (38%), or dependent (26%). However, it was found that, with less dependence, there was more impaired skin integrity. This discrepancy may arise from the fact that, firstly, the samples were not directly comparable. Secondly, this is an ND with a high abstraction level, meaning that it is too broad to carry out a precise interpretation. Any abnormality of the epidermis or dermis will come under this category. The aim of our study was not to discuss how much detail an ND should have; however, it is clear that, in this specific case, both in clinical practice and in interpreting the data, it should at least be accompanied by its DCs, i.e., its clinical manifestations, as well as the related factors.
In terms of risk for falls, it seems to be an underestimation that only one in four HCCPs suffer from this potential issue. The literature shows that three in 10 people over the age of 65 living in the community suffer falls each year [
38]. In this study population, in seven out of 10 patients assessed, the nurse indicated that the HP physical activity/exercise was altered. People with higher levels of disability present a greater risk [
39], which agrees with the data from our investigation, where the prevalence of risk for falls in dependent, frail, and independent people was 46%, 38%, and 16%, respectively. In future studies, it would be worthwhile to include an assessment of intrinsic and extrinsic factors that increase risk, such as those identified by other authors as more frequent factors. These include visual impairment, mobility issues, history of falls, inadequate resources in the bathroom, and loose rugs [
40]. In addition, a validated scale, test, or tool to measure risk should be considered [
41].
Logically, at present, it seems that the ND that most fits the HCCP profile may be frail elderly syndrome. It was included in the NANDA-I classification in 2013 and is defined as the dynamic state of unstable equilibrium that affects the older individual experiencing deterioration in one or more domains of health (physical, functional, psychological, or social) and leads to increased susceptibility to adverse health effects, particularly disability. It has a level of evidence of 2.1, meaning that, until now, it has not been clinically validated with a large sample of patients. According to NANDA-I, a syndrome is defined as ‘a clinical judgement concerning a specific cluster of nursing diagnoses that occur simultaneously and are best addressed together and through similar intervention’ [
42], and it must include a minimum of two NDs, meaning it has a significant impact on several human responses [
43].
Frail elderly syndrome is directly present in only 9% of HCCPs. However, when we add patients who meet diagnostic criteria to this group, we found that 23% of patients suffered from this issue, which would position it as the fourth most common ND. The infrequent recording of this syndrome by community nurses in PC in our context, compared to the number of patients who meet the diagnosis criteria, could be due to various reasons. On the one hand, it was included in the NANDA-I classification of 2013, which makes it a more recent addition compared to other NDs that have been part of the classification system for longer. On the other hand, it seems to be easier to identify the records of each ND that makes up the syndrome rather than the syndrome itself. To properly plan and manage care, the assessment should be more in depth and specify which DC led to the diagnosis.
The majority of patients diagnosed with frail elderly syndrome or who met two or more of the DCs for this issue were women, at 60%. This coincides with data from the ENS in Spain, in which women reported a higher frequency of limitations than men. This gap by gender is common across all disability indicators [
4].
In Spain, 20–40% of older people experience social isolation and loneliness [
44]. This figure is considerably higher than what we found in our study on HCCPs, where 11% of patients live alone and only 2% of them present the NDs of social isolation and risk for loneliness, according to EHR records. The consequences of loneliness on health and quality of life for older people are well known [
45], being linked to a considerably higher morbidity rate [
46,
47], which agrees with the results of our investigation. Other problems referred to previously are more common in HCCPs who live alone: risk for falls, social isolation, situational low self-esteem, chronic low self-esteem, impaired home maintenance, anxiety, ineffective health management, ineffective coping, impaired memory, insomnia, and self-care deficits (bathing, dressing, and feeding). This determines the type of care needs of these HCCPs who live alone and informs their care plan.
It is noteworthy that more than 95% of patients included in the investigation were seen by their nurse or general practitioner in the last year. As a result, these patients are well known by the referring healthcare team, making their assessment, management, and care much easier. Among other factors, advanced age and chronicity are associated with frequent attendance and overuse of PC [
48]. It is known that older patients, higher-risk patients, and higher-complexity patients use health resources more frequently [
49]. There is no consensus in the literature to describe a hyperfrequent-attending patient, as it generally uses arbitrary methods instead [
50]. With the variables under study, we were unable to determine the profile of a hyperfrequent-attending HCCP or the needs left uncovered that may have arisen from this increased demand.
In theory, the liaison nurse or nurse case manager is the health professional who should lead HCCP care. As suggested by Mármol and López, independent of the conceptual framework, all of the implemented strategies and initiatives point to the PC, particularly the community nurse as guarantors of providing care to chronically ill patients, their families, and the community [
51]. Theoretically, follow-up by the liaison community nurse has a positive impact on coverage and hospitalization outcomes, pressure injuries, falls, caregiver role strain, assessing social risk, and home visits from referral healthcare professionals in PC. Therefore, this could be an efficient alternative in providing care to the polypathological, polymedicated, and dependent groups of the population [
52]. However, similar to findings from our study, only 20% of these patients have been visited by the liaison nurse. This could be related to the unequal implementation of this figure in the ACCI, whereby these professionals cannot cover every basic healthcare district; rather, they are distributed, in general, in areas where the population is more spread out and hard to access, primarily due to the relief of the terrain.
This investigation presented some limitations for consideration, particularly those deriving from its retrospective nature, i.e., carried out using EHR records and not with a direct longitudinal assessment of each chronic patient. In addition, in some cases, the diagnostic label could be interpreted with a high level of abstraction, being too broad. It may be worthwhile in future studies to explore other components of NDs, such as DCs, related factors, and risk factors within the initial diagnostic labels identified by nurses. Furthermore, regarding measuring instruments used (scales, tests, or questionnaires), each one of their dimensions should be examined with, instead of just, their final score. This would allow for the identification of specific areas of dysfunction regarding the components of said instruments. Within this line of research, for the identification of the HCCP, it is suggested to include certain NDs considered as especially sensitive among these patients, such as risk for falls, bathing self-care deficit, impaired skin integrity, and frail elderly syndrome. Departing from this epidemiological study, a new working hypothesis can be formulated and new research plans can be built that allow determining the weight and influence of care needs identified by the community nurse in terms of the degree of complexity of the chronic patient.