[Implementation of an integrated nursing liaison model: a descriptive study]

To evaluate the implementation of a liaison nursing model that integrates primary care and hospital functions and to analyze the role of this model in situations of dependency.

We performed an analytical-observational study of demand for liaison in continuity of care during the first year after implementation of the model. Patients were classified into six categories. The degree dependency was established by means of the Barthel index and Virginia Henderson's needs.

A total of 515 cases of liaison were observed (women: 57.3%, age: 69.32 +/- 18.25). Origin: hospital (78.1%), primary care (21.9%); destination: hospital (6.8%), primary care (82.1%), other (11.1%). Most frequent patient profile: continuity of cures/techniques. Main altered needs: hygiene/skin (65.8%), movement (55.5%), dressing (47.4%) and elimination (26.2%). Degree of dependency: no dependency (15.2%), slight dependency (62.7%), moderate dependency (3.4%), high dependency (18%). The degree of dependency was lower in hospital demand than in primary care demand (p<0.001). Other services involved: social work (21.7%), Functional Interdisciplinary Social-Health Unit (10.3%), Administration (5%), Domiciliary Care Support Team Program (4.7%), Residential Physio-Rehabilitation Team (3.9%). ProdeP project (people over 65): 37.5% showed dependency (low dependency [14.5%], moderate [33%], high or complete dependency [52.5%]).

TThe highest flow was from the hospital setting to primary care, with a lower degree of dependency but greater urgency in the provision of continuity of care. We observed a high percentage of dependency. The liaison nursing model facilitates provision of coordinated and comprehensive care, with a high component of situations of dependency.