The Nurse Case Manager in the Simultaneous Care Multidisciplinary Oncology Group: Never Alone Again

Abstract

Introduction. Introduction: Simultaneous care integrates palliative care with active treatment from the early stages of illness. Disease-related burden, complex appointment management, and fragmented hospital organization may generate helplessness, vulnerability, loneliness, and disorientation among patients, families, and caregivers. Within the simultaneous care multidisciplinary oncology group, the nurse case manager facilitates access to services and diagnostic examinations, integrates the pathway agreed upon with patients and specialists, plans nursing care according to the Gordon-NANDA-I-NOC-NIC model, and promotes continuity between hospital and community services. This project aimed to evaluate the contribution of the nurse case manager to simultaneous care pathways, particularly in improving quality of life through timely symptom management at home and reducing emergency medical service calls, emergency department visits, and repeated hospitalizations.

Methods. The project combined a review of national and international literature on case management models in oncology and palliative care with a descriptive analysis of clinical cases managed during the first six months of implementation. The analysis considered adherence to medical and surgical treatments, waiting times for examinations and specialist visits, professional integration between hospital and community services, and patient- and family-perceived quality of care.

Results. The introduction of the nurse case manager was associated with reduced fragmentation of hospital services, improved coordination among healthcare professionals, and more timely activation of home care. The model also supported greater integration between hospital and community services throughout the care pathway.

Discussion. The nurse case manager may act as a facilitator by integrating clinical, organizational, and relational competencies. Personalized care requires respect for patients’ preferences and availability, shared decision-making concerning quality and quantity of life, and progressive listening throughout the disease trajectory. Quantitative evaluation is required to determine the model’s effects on healthcare utilization, treatment adherence, symptom management, and perceived quality of care.