Improving Health Outcomes through Nurse-Led Monitoring Models: Evidence from a Longitudinal Evaluation of Multimorbidity Care
DOI:
https://doi.org/10.61978/curatio.v2i4.1407Keywords:
Nurse-Led Care, Outcome-Based Evaluation, Multimorbidity, Patient Activation, Chronic Disease Management, Treatment Burden, Standardized OutcomesAbstract
Multimorbidity presents major challenges for delivering coordinated, patient-centered chronic care. This study developed and evaluated a structured, outcome-based, nurse-led framework to monitor and improve health outcomes among adults with multiple chronic conditions. Using a longitudinal observational design, patients were assessed at baseline, weeks 8–12, and quarterly using validated instruments: EQ-5D (health-related quality of life), PAM (patient activation), PHQ-9/GAD-7 (mental health), MTBQ (treatment burden), and PACIC (care coordination experience). Standardized outcome terminologies, such as NOC, were incorporated to enhance reproducibility. Data were analyzed using descriptive and inferential statistics, including repeated-measures and correlation analyses. Results showed significant improvements in health-related quality of life, mental health, and patient activation. PAM scores were strongly and inversely associated with emergency department visits, and positively associated with PACIC scores. PHQ-9 and MTBQ scores decreased, reflecting reduced psychological distress and treatment burden. Standardized terminologies enabled effective mapping of nursing interventions to patient outcomes. These findings support the scientific and practical value of outcome-based models in nurse-led care for complex populations, enhancing the visibility, consistency, and effectiveness of nursing practice in chronic disease management. The framework offers a scalable, patient-centered approach and lays groundwork for future research and policy development in outcome-based chronic care.
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