[Continuity of care: role of the link nurse]

To evaluate the link nurse programme after 2 years of operation.

Descriptive study.

Primary vare in the towns of Sant Boi de Llobregat and Sant Vicenç dels Horts (Barcelona) and the County Hospital of Sant Boi, Spain.

Patients discharged from the hospital (October 2000-October 2002) and who needed ongoing care in the primary care centre or at home.

Joint visits of the link nurse and the hospital unit's supervisor to work out the care plan before discharge. The PC team was informed of the transfer of the patient and his/her care plan. Subsequent home visits were by the link nurse, the primary care team or both together.

854 patients (57.6% women) were studied. Women's mean age was 69.82 (SD, 4.7) and men's was 61.7 (SD, 9.6) (P<.0001). The link nurse made 2241 hospital visits, 81 home visits, and 434 phone calls. There were 636 co-ordinations. The most common nursing diagnosis made was physical mobility disorder (61% of patients).

A mechanism was created to improve continuity from hospital discharge to contact with the PC team. The link nurse coordinates and manages patients before they are handed over to PC.