This study aimed to evaluate the functional impact of a shared intervention model by the mobile physiotherapy and rehabilitation team (MPRT) and primary care case management nurses (PCCMNs) on chronic patients. This was a prospective, observational study involving 1086 patients (mean age, 80 years; 63.7% females) in the province of Almeria, which was conducted between 2004 and 2018. Most of the registered diseases included cerebrovascular and neurological diseases (56.7%), osteoarticular diseases (45.3%), diabetes mellitus (25.7%), cardiovascular diseases (25.5%), and chronic respiratory diseases. The study included a home care intervention by the MPRT and PCCMNs and included the following main outcome measures: age, sex, main caregiver, disabling process (ICD-9), type and number of inclusion categories for chronic disease, initial and final Barthel index (BI), treatment or intervention on the patient (techniques), objectives, and number of sessions. The main techniques used were kinesiotherapy (44.6%) and caregiver training (23%), along with technical aid. An equation predicting the patients' final BI, according to the initial BI, was constructed using multiple linear regression modelling. A marked improvement in functional capacity was found after an average of 10 physiotherapy sessions. A lower patient age was correlated with a higher functional capacity, both initial and final BI, as well as a greater number of sessions.
Keywords: case management; chronic condition; functional independence; home health care; multiple pathology; physiotherapy.