Chronic Diseases in Primary Care

The study aims to evaluate the effectiveness of managing people with chronic diseases through structured patient education, proactive healthcare, and prevention programs in primary care.

The intervention will be carried out in the outpatient setting and delivered by family and community nurses working in a Community Health Home, located in a rural district in northern Italy.

The quasi-experimental study takes place from September 2023 to September 2025.

• Population - All patients meeting the following inclusion criteria will be included: a) diagnosed with at least one non-oncological chronic condition, b) aged over 65 years, and c) assigned to general practitioners in the district of reference of the Community Health Home. Potential participants will be referred by general practitioners, social workers, or other professionals from home care, community, and transitional care services to family and community nurses (hereafter, nurses). Nurses will collect the informed written consent to participate in the study. Patients will be recruited through a consecutive sampling. It wasn't possible to perform an a priori power analysis because there are no available data on the chosen primary endpoint.
• Educational Intervention - The intervention will involve nurses proactively caring for patients with chronic conditions based on the Chronic Care Model approach and the Middle Range Theory of self-care in chronic disease, focusing on behavior change, engagement and empowerment, self-care and symptom perception, and health promotion planning strategies.

This process will be initiated through a phone call, during which the service will be introduced, and an appointment will be scheduled for either an outpatient or home nursing visit, depending on the patient's ability to access the Community Health Home. Following the initial structured assessment interview, patients will receive structured follow-up care with at least three contacts over six months. The frequency of these contacts will be increased at the nurse's discretion in cases of poor self-care ability or multiple educational needs identified during the initial interview. The follow-up will consist of in-person visits alternated with telephone follow-ups, focusing on self-care skill development and clinical monitoring.

Nurses will be trained on the study by a researcher in three meetings of two hours to ensure that all nurses carry out the intervention uniformly and reliably.

-Therapeutic education-

To assess educational needs, on the first interview, nurses will collect:

i) Socio-demographic data, as age, sex, informal caregiver(s) of reference, and cohabitation status; ii) Priority needs of the patients and informal caregivers through open-ended questions.

iii) Data from clinical conditions, as weight, height, vital signs, diseases, medications, blood tests, and medical exams, and civil disability status.

At the end, nurses will perform a structured assessment of social and educational needs in terms of:

• lifestyle (level of physical activity, alcohol consumption, sleeping quality, smoking habit);
• self-care skills (Patient Activation Measure questionnaire);
• risk of clinical-social frailty (Sunfrail questionnaire).

If any concerns or issues emerge, other questionnaires will be used for specific problems. All questionnaires will be used in their validated Italian versions and compiled into a pre-filled Excel file for each patient, created by the researchers.

These elements will be pre-filled based on data inputted by nurses and finalized manually. All information will be incorporated into an educational plan, which will be provided to the patient in written form.

Throughout all interviews, four communication approaches will be implemented:

• Teach-back, to assess an individual's understanding of newly acquired information;
• Motivational Interviewing, a counseling approach that facilitates collaborative dialogues to elicit the individual's intrinsic reasons for change, commitment.
• Sharing Evidence Routine for a Person-centred Plan for Action (SHERPA model), a structured shared decision-making approach;
• Family interviews according to the Calgary Family Assessment and Intervention Models, designed to support families as a unit, strengthening resilience and self-care.

• Outcomes - The primary clinical outcome will be a composite outcome, assessed at 6 and 12 months: access to the emergency department and/or hospitalization.

Secondary outcomes include quality of care and medication adherence, and self-care abilities. These will be assessed with Patient-Reported Experience Measures (PREMs), questionnaires, and other indicators related to the process (number of visits, number of prescriptions, number of activated services).

-Data Collection- Nurses' charts (Excel files) and hospital and pharmaceutical databases will be used by authorised members to extract data.

• Statistical Analysis- Descriptive statistics will be employed by researchers to summarize socio-demographic characteristics. The Wilcoxon signed-rank test and McNemar's test will be used to compare pre-post-intervention outcomes.

Primary and secondary outcomes will be analyzed according to the intention-to-treat principle at the level of individual participants. Changes in repeated measures over time will be evaluated, with adjustments for baseline confounders. To further increase the transparency of results, researchers will evaluate to perform a sensitivity analysis. Cost analysis will be considered, taking into account human resources involved, materials, technologies, and savings from avoided hospitalizations and emergency care.

Inclusion criteria

• Diagnosed with at least one non-oncological chronic condition;
• Aged over 65 years;
• Assigned to general practitioners in the district of reference of the Community Health Home.

Exclusion criteria

• Life expectancy of less than 12 months, as assessed by the general practitioner;
• Having more than one home access a week of intensive home care.