{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,16]],"date-time":"2026-07-16T03:33:17Z","timestamp":1784172797626,"version":"3.55.0"},"reference-count":52,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2022,12,20]],"date-time":"2022-12-20T00:00:00Z","timestamp":1671494400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Fundaci\u00f3n Canaria Instituto de Investigaci\u00f3n Sanitaria de Canarias","award":["ENF-19\/26"],"award-info":[{"award-number":["ENF-19\/26"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Nursing Reports"],"abstract":"<jats:p>In the last few decades, the impact of chronic health conditions on health systems, as well as on the quality of life, frailty, and dependence of those affected, has been brought to light. The objective of this study was to describe the population care needs of highly complex chronic patients (HCCPs). Methods: An epidemiological observational study was conducted. Results: A total of 13,262 patients were identified, 51% of which were elderly women. Among all patients, 84.4% had received a nursing assessment related to health patterns. Three diagnoses were established in 25% of the sample: readiness for enhanced health management, impaired skin integrity, and risk for falls. There were significant differences according to age, most importantly in terms of impaired skin integrity (39% of patients under 80 years old). 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 were more common in those living alone. A total of 37 diagnoses featured differences according to frailty\/dependence. Approximately 23% of HCCPs suffered from frail elderly syndrome. Conclusions: This study presents the most common care needs of HCCPs, describing the sociodemographic profile of this part of the population. The planning of HCCP care varies in nature. Factors such as the dependence level and frailty of these people should be taken into consideration.<\/jats:p>","DOI":"10.3390\/nursrep13010001","type":"journal-article","created":{"date-parts":[[2022,12,21]],"date-time":"2022-12-21T04:28:55Z","timestamp":1671596935000},"page":"1-16","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Care Needs of Highly Complex Chronic Patients in the Canary Islands: An Observational Study"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7129-0912","authenticated-orcid":false,"given":"Mart\u00edn","family":"Rodr\u00edguez-\u00c1lvaro","sequence":"first","affiliation":[{"name":"The Canary Islands Health Service, Nursing Department, Faculty of Healthcare Sciences, University of La Laguna, 38200 Santa Cruz de Tenerife, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9151-6579","authenticated-orcid":false,"given":"Domingo \u00c1ngel","family":"Fern\u00e1ndez-Guti\u00e9rrez","sequence":"additional","affiliation":[{"name":"The Canary Islands Health Service, Nursing Department, Faculty of Healthcare Sciences, University of La Laguna, 38200 Santa Cruz de Tenerife, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Antonio","family":"Cabeza-Mora","sequence":"additional","affiliation":[{"name":"Primary Care Management of Gran Canaria, The Canary Islands Health Service, 35006 Las Palmas de Gran Canaria, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rosario","family":"Barrios-Torres","sequence":"additional","affiliation":[{"name":"Primary Care Management of Gran Canaria, The Canary Islands Health Service, 35006 Las Palmas de Gran Canaria, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"name":"Nursing Methodology Group General Directorate of Health Care Programs of the Canary Islands Health Service (Primary Care)","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8048-9701","authenticated-orcid":false,"given":"Pedro Ruym\u00e1n","family":"Brito-Brito","sequence":"additional","affiliation":[{"name":"The Canary Islands Health Service, Nursing Department, Faculty of Healthcare Sciences, University of La Laguna, 38200 Santa Cruz de Tenerife, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2022,12,20]]},"reference":[{"key":"ref_1","first-page":"2","article-title":"Chronic disease management: What will it take to improve care for chronic illness?","volume":"1","author":"Wagner","year":"1998","journal-title":"Eff. Clin. Pract."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"e018","DOI":"10.5334\/ijic.2246","article-title":"PRISMA: Program of Research to Integrate the Services for the Maintenance of Autonomy. A system-level integration model in Quebec","volume":"15","author":"MacAdam","year":"2015","journal-title":"Int. J. Integr. Care"},{"key":"ref_3","unstructured":"Pines, J., Selevan, J., McStay, F., George, M., and McClellan, M. (2022, August 31). Kaiser Permanente\u2014California: A Model for Integrated Care for the Ill and Injured. The Brookings Institution. Available online: https:\/\/www.brookings.edu\/wp-content\/uploads\/2015\/04\/050415EmerMedCaseStudyKaiser.pdf."},{"key":"ref_4","unstructured":"Ministerio de Sanidad, Consumo y Bienestar Social (2019). Encuesta Nacional de Salud ENSE, Espa\u00f1a 2017."},{"key":"ref_5","unstructured":"Instituto Canario de Estad\u00edstica (2013\u20132019). Encuesta de Condiciones de Vida\/Resultados Principales."},{"key":"ref_6","unstructured":"Ministerio de Sanidad, Servicios Sociales e Igualdad (2022, September 21). Estrategia Para el Abordaje de la Cronicidad en el Sistema Nacional de Salud, Available online: https:\/\/www.sanidad.gob.es\/organizacion\/sns\/planCalidadSNS\/pdf\/ESTRATEGIA_ABORDAJE_CRONICIDAD.pdf."},{"key":"ref_7","unstructured":"Clinical Risk Groups (2022, September 21). 3 MTM Health Information Systems. Available online: http:\/\/solutions.3m.com\/wps\/portal\/3M\/enUS\/Health-Information-Systems\/HIS\/Products-and-Services\/Products-List-A-Z\/Clinical-Risk-Grouping-Software."},{"key":"ref_8","unstructured":"The Johns Hopkins (2022, September 21). ACG(r) System. Available online: http:\/\/acg.jhsph.org."},{"key":"ref_9","unstructured":"Ministerio de Sanidad, Consumo y Bienestar Social (2022, September 21). Informe del Proyecto de Estratificaci\u00f3n de la Poblaci\u00f3n por Grupos de Morbilidad Ajustados (GMA) en el Sistema Nacional de Salud (2014\u20132016), Available online: https:\/\/www.sanidad.gob.es\/en\/organizacion\/sns\/planCalidadSNS\/pdf\/informeEstratificacionGMASNS_2014-2016.pdf."},{"key":"ref_10","first-page":"e202007079","article-title":"Validaci\u00f3n del poder predictivo de los Grupos de Morbilidad Ajustada (GMA) respecto de otras herramientas de estratificaci\u00f3n de la poblaci\u00f3n","volume":"94","year":"2020","journal-title":"Rev. Espa\u00f1ola Salud P\u00fablica"},{"key":"ref_11","unstructured":"Ministerio de Sanidad, Servicios Sociales e Igualdad (2022, September 21). Estrategia Para el Abordaje de la Cronicidad en el Sistema Nacional de Salud. Informe de Evaluaci\u00f3n y L\u00edneas Prioritarias de Actuaci\u00f3n, Available online: https:\/\/www.sanidad.gob.es\/organizacion\/sns\/planCalidadSNS\/pdf\/Evaluacion_E._Cronicidad_Final.pdf."},{"key":"ref_12","unstructured":"Alfaro Lefevre, R. (2005). Aplicaci\u00f3n del Proceso Enfermero. Fomentar el Cuidado en Colaboraci\u00f3n, Masson. [5th ed.]."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Gordon, M. (1994). Nursing Diagnosis: Process and Application, Mosby. [3rd ed.].","DOI":"10.1097\/00003465-199411000-00014"},{"key":"ref_14","unstructured":"Herdman, T.H., Kamitsuru, S., and Tak\u00e1o Lopes, C. (2021). Nursing diagnoses. Definitions and Classification 2021\u20132023, Thieme. [12th ed.]."},{"key":"ref_15","unstructured":"Moorhead, S., Swanson, E., Johnson, M., and Maas, M.L. (2019). Clasificaci\u00f3n de Resultados de Enfermer\u00eda (NOC), Elsevier. [6th ed.]."},{"key":"ref_16","unstructured":"Butcher, H.K., Bulechek, G.M., Dochterman, J.M., and Wagner, C.M. (2019). Clasificaci\u00f3n de Intervenciones de Enfermer\u00eda (NIC), Elsevier. [7th ed.]."},{"key":"ref_17","unstructured":"Ministerio de Sanidad y Pol\u00edtica Social (2022, August 31). Gobierno de Espa\u00f1a. Real Decreto 1093\/2010, de 3 de Septiembre, por el que se Aprueba el Conjunto M\u00ednimo de Datos de los Informes Cl\u00ednicos en el Sistema Nacional de Salud. Available online: https:\/\/www.boe.es\/eli\/es\/rd\/2010\/09\/03\/1093\/dof\/spa\/pdf."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1495","DOI":"10.1016\/j.ijsu.2014.07.013","article-title":"The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for reporting observational studies","volume":"12","author":"Altman","year":"2014","journal-title":"Int. J. Surg."},{"key":"ref_19","first-page":"41","article-title":"M\u00f3dulo de metodolog\u00eda enfermera en Drago-AP","volume":"2","year":"2008","journal-title":"Rev. Ene Enfermer\u00eda"},{"key":"ref_20","first-page":"e19937","article-title":"The Impact of Charlson Comorbidity Index on Mortality From SARS-CoV-2 Virus Infection","volume":"13","author":"Ahmed","year":"2021","journal-title":"Cureus"},{"key":"ref_21","first-page":"239","article-title":"Resultados de la aplicaci\u00f3n de una escala de valoraci\u00f3n sociofamiliar en Atenci\u00f3n Primaria","volume":"29","year":"1994","journal-title":"Rev. Espa\u00f1ola  Geriatr\u00eda Gerontol."},{"key":"ref_22","first-page":"129","article-title":"Adaptaci\u00f3n y validaci\u00f3n al castellano del cuestionario de Pfeiffer (SPMSQ) para detectar la existencia de deterioro cognitivo en personas mayores de 65 a\u00f1os","volume":"117","year":"2001","journal-title":"Med. Cl\u00edn."},{"key":"ref_23","first-page":"32","article-title":"\u00cdndice de Barthel: Instrumento v\u00e1lido para la valoraci\u00f3n funcional de pacientes con enfermedad cerebrovascular","volume":"28","year":"1993","journal-title":"Rev. Espa\u00f1ola  Geriatr\u00eda Gerontol."},{"key":"ref_24","unstructured":"Rea, L.M., and Parker, R.A. (1992). Designing and Conducting Survey Research: A Comprehensive Guide, Jossey-Bass Publishers."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"107","DOI":"10.1016\/j.aprim.2011.01.013","article-title":"La atenci\u00f3n al paciente cr\u00f3nico en situaci\u00f3n de complejidad: El reto de construir un escenario de atenci\u00f3n integrada","volume":"44","author":"Contel","year":"2012","journal-title":"Atenci\u00f3n Primaria"},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Company-Sancho, M.C., Gonz\u00e1lez-Chord\u00e1, V.M., and Orts-Cort\u00e9s, M.I. (2022). Variability in Healthcare Expenditure According to the Stratification of Adjusted Morbidity Groups in the Canary Islands (Spain). Int. J. Environ. Res. Public Health, 19.","DOI":"10.3390\/ijerph19074219"},{"key":"ref_27","unstructured":"Echevarr\u00eda, P. (2016). Investigaci\u00f3n epidemiol\u00f3gica en diagn\u00f3sticos enfermeros. Investigaci\u00f3n en Metodolog\u00eda y Lenguajes Enfermeros, Elsevier."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"60","DOI":"10.1016\/j.gaceta.2017.06.003","article-title":"Comparaci\u00f3n de modelos predictivos para la selecci\u00f3n de pacientes de alta complejidad","volume":"33","year":"2019","journal-title":"Gac. Sanit."},{"key":"ref_29","first-page":"214","article-title":"The connection between nursing diagnosis and the use of healthcare resources","volume":"27","year":"2017","journal-title":"Enferm. Clin."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"34","DOI":"10.1111\/2047-3095.12202","article-title":"The Grieving Nursing Diagnoses in the Primary Healthcare Setting","volume":"30","year":"2019","journal-title":"Int. J. Nurs. Knowl."},{"key":"ref_31","first-page":"8","article-title":"Impacto del duelo complicado. una lectura a trav\u00e9s del lenguaje del cuidado","volume":"13","year":"2019","journal-title":"Rev. Ene Enfermer\u00eda"},{"key":"ref_32","first-page":"13","article-title":"Duelo inadaptado en personas fr\u00e1giles y dependientes de Canarias","volume":"10","year":"2022","journal-title":"RqR Enfermer\u00eda Comunitaria"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"112","DOI":"10.1111\/j.1440-172X.2009.01815.x","article-title":"A meta-study of the essentials of quality nursing documentation","volume":"16","author":"Jefferies","year":"2010","journal-title":"Int. J. Nurs. Pract."},{"key":"ref_34","unstructured":"Herdman, T.H. (2012\u20132014). El valor de los diagn\u00f3sticos enfermeros en los registros de salud electr\u00f3nicos. Diagn\u00f3sticos Enfermeros, Elsevier. Definiciones y clasificaci\u00f3n."},{"key":"ref_35","unstructured":"Guirao, J.A., Cama\u00f1o, R.E., and Cuesta, A. (2001). Investigaci\u00f3n en nomenclatura enfermera. Diagn\u00f3stico Enfermero, Ediversitas Multimedia."},{"key":"ref_36","first-page":"1132","article-title":"Utilizaci\u00f3n del proceso enfermero en atenci\u00f3n primaria en Canarias","volume":"15","year":"2021","journal-title":"Ene"},{"key":"ref_37","first-page":"134","article-title":"Prevalencia de lesiones por presi\u00f3n y otras lesiones cut\u00e1neas relacionadas con la dependencia en centros de atenci\u00f3n primaria de salud de Espa\u00f1a en 2017","volume":"30","year":"2019","journal-title":"Gerokomos"},{"key":"ref_38","first-page":"CD007146","article-title":"Interventions for preventing falls in older people living in the community","volume":"9","author":"Gillespie","year":"2012","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"274","DOI":"10.1016\/j.regg.2015.05.005","article-title":"Ca\u00eddas en la poblaci\u00f3n anciana espa\u00f1ola: Incidencia, consecuencias y factores de riesgo","volume":"50","author":"Narvaiza","year":"2015","journal-title":"Rev. Espa\u00f1ola  Geriatr\u00eda Gerontol."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"e20180826","DOI":"10.1590\/0034-7167-2018-0826","article-title":"Nursing diagnosis Risk for Falls in the elderly in primary health care","volume":"73","author":"Santos","year":"2020","journal-title":"Rev. Bras.  Enferm."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1007\/s40520-017-0749-0","article-title":"Tools for assessing fall risk in the elderly: A systematic review and meta-analysis","volume":"30","author":"Park","year":"2018","journal-title":"Aging Clin. Exp. Res."},{"key":"ref_42","unstructured":"NANDA International (2015). The Structure and Development of Syndrome Diagnoses [Internet], NANDA-I (US). Available online: http:\/\/www.nanda.org\/nanda-i-resources\/position-statement\/."},{"key":"ref_43","unstructured":"Brito Brito, P.R. (2022, September 22). El s\u00edndrome de shock emocional y el s\u00edndrome de disrupci\u00f3n social: Nuevas propuestas de diagn\u00f3sticos enfermeros. Revista Ene de Enfermer\u00eda, Available online: http:\/\/ene-enfermeria.org\/ojs\/index.php\/ENE\/article\/view\/920."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"224","DOI":"10.1016\/j.aprim.2018.09.012","article-title":"Perfiles de soledad y aislamiento social en poblaci\u00f3n urbana","volume":"52","author":"Comice","year":"2020","journal-title":"Atenci\u00f3n Primaria"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"102218","DOI":"10.1016\/j.aprim.2021.102218","article-title":"Condicionantes para el abordaje del aislamiento social y la soledad de adultos mayores no institucionalizados desde atenci\u00f3n primaria de salud","volume":"54","year":"2022","journal-title":"Atenci\u00f3n Primaria"},{"key":"ref_46","first-page":"176","article-title":"Social isolation and loneliness: The new geriatric giants: Approach for primary care","volume":"66","author":"Freedman","year":"2020","journal-title":"Can. Fam. Physician"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"443","DOI":"10.1159\/000441651","article-title":"Loneliness and Health in Older Adults: A Mini-Review and Synthesis","volume":"62","author":"Ong","year":"2016","journal-title":"Gerontology"},{"key":"ref_48","first-page":"484","article-title":"Estudio comparativo entre poblaci\u00f3n normo e hiperfrecuentadora en un centro de salud","volume":"18","year":"1996","journal-title":"Atenci\u00f3n Primaria"},{"key":"ref_49","doi-asserted-by":"crossref","unstructured":"Barrio-Cortes, J., Casta\u00f1o-Reguillo, A., Beca-Mart\u00ednez, M.T., Bandeira-de Oliveira, M., L\u00f3pez-Rodr\u00edguez, C., and Jaime-Sis\u00f3, M.\u00c1. (2021). Chronic diseases in the geriatric population: Morbidity and use of primary care services according to risk level. BMC Geriatr., 21.","DOI":"10.1186\/s12877-021-02217-7"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"631","DOI":"10.1016\/S0212-6567(08)75697-X","article-title":"Los hiperfrecuentadores en atenci\u00f3n primaria: Perfil sociodemogr\u00e1fico, caracter\u00edsticas cl\u00ednicas y propuesta de una nueva definici\u00f3n","volume":"40","year":"2008","journal-title":"Atenci\u00f3n Primaria"},{"key":"ref_51","first-page":"e201806032","article-title":"Impacto de las intervenciones enfermeras en la atenci\u00f3n a la cronicidad en Espa\u00f1a. Revisi\u00f3n sistem\u00e1tica","volume":"92","year":"2018","journal-title":"Rev. Espa\u00f1ola  Salud P\u00fablica"},{"key":"ref_52","unstructured":"Duarte Cl\u00edments, G. (2016). Evaluaci\u00f3n del Modelo de Gesti\u00f3n de Casos en Atenci\u00f3n Primaria Mediante Enfermeras Comunitarias de Enlace. [Ph.D. Thesis, Universidad de La Laguna]."}],"container-title":["Nursing Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2039-4403\/13\/1\/1\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T01:44:53Z","timestamp":1760147093000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2039-4403\/13\/1\/1"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,12,20]]},"references-count":52,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2023,3]]}},"alternative-id":["nursrep13010001"],"URL":"https:\/\/doi.org\/10.3390\/nursrep13010001","relation":{},"ISSN":["2039-4403"],"issn-type":[{"value":"2039-4403","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,12,20]]}}}