Enfermeiro gestor de caso no acompanhamento de utentes crónicos em ambiente hospitalar na transição para a comunidade: scoping review

The hospital-to-community transition is a critical time for chronic patients, with an increased risk of readmission and gaps in care continuity. The case manager nurse has been suggested as a strategy to improve coordination, patient experience, and clinical outcomes. Our goal was to map the literature published between 2021-2026 on case manager nurse-led interventions for chronic patients in hospital settings and during the transition to the community, describing the models, components, effectiveness, and research gaps. Current evidence mainly focuses on patients gaining self-management skills and the role of informal caregivers in care transitions. For the methodology, we chose to conduct a scoping review based on searches in the PubMed/MEDLINE, CINAHL, and Scopus databases. Studies in English, Portuguese, and Spanish were included. Two independent reviewers performed the screening and standardized extraction. We followed the Joanna Briggs Institute guidance protocol for scoping reviews, with the corresponding registration on the platform. After analyzing the retrieved articles, 10 studies were included. The evidence indicates a reduction in readmissions and emergency visits when nurse case manager interventions are followed up for more than 12 weeks. Also, early post-discharge contact tends to show better outcomes in health service use. The models vary between risk identification, therapeutic reconciliation, and contact within 72 hours. The nurse case manager contributes to improved coordination (readmissions, adherence to therapy, patient satisfaction, and quality of life), but robust studies in the hospital setting are lacking. It appears to be a promising intervention for the transition of chronic patients; however, implementation studies in the national context are needed to optimize models and demonstrate cost-effectiveness.