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care management, cardiology, home care, nursing



  1. Morin, Diane PhD, RN
  2. Aubin, Michele MD, FCMF
  3. Vezina, Lucie MA
  4. Gagnon, Johanne PhD, RN
  5. Racine, Sandra MSc, RN
  6. Reinharz, Daniel PhD, MD
  7. Paradis, Michele MSc
  8. Dallaire, Clemence PhD, RN
  9. Aubin, Karine MSc


Purpose/objectives: This quasi-experimental research aims to (1) evaluate the implementation process of a community nursing care management model and (2) assess the effects of this model on patients followed at home.


Primary practice setting: Two community healthcare centers had introduced a community nursing care management model in their practice (experimental groups), whereas another health community care center with no experience with such a model served as a control group. The community nursing care management model included clinical pathways designed for a clientele who had been hospitalized for cardiac surgery.


Findings/conclusions: Even though the implementation process was challenging, the community nursing care management model was found useful enough to be integrated into routine nursing home care practice after cardiac surgery. Although the effects produced by this systematic home care program on the clientele did not differ significantly from those produced by usual nursing care, there was a positive effect for the clientele recorded on all measurement indicators used.


Implications for case management practice: The introduction of the nursing care management model enabled nurses to structure the care provided and reduced interindividual variation. The application of this program also proved to be an opportunity to initiate and assimilate new professional roles. Additional studies should be conducted to assess its effectiveness in home care for other health problems.