The sustained increase in life expectancy over recent decades represents one of the greatest successes of

highlighting the need for more integrated, personalised, and continuity-based responses—within which case

Data presented in the Access, Performance and Health Indicators Report (RADIS, 2025)³ and in Health at a

longer lies solely in responding to acute episodes associated with chronic disease, but rather in the capacity to

design and operationalise continuous, integrated and genuinely person-centred models of care for people living

with chronic and complex conditions.²˒³ Against this backdrop, reflection on the adequacy of current

organisational models in addressing the complexity of chronicity becomes imperative—a reflection to which

this editorial explicitly seeks to contribute, grounded in key international frameworks and the evidence available

for the Portuguese context.

Scientific evidence indicates that care trajectories associated with complex chronicity are frequently

characterised by identity and relational discontinuity, fragmentation of clinical information, and deficits in

coordination across levels of care—factors associated with poorer clinical outcomes, greater avoidable service

use and negative patient experiences.⁹–¹¹ In this context, patient experience—assessed through patient-reported

outcomes and patient-reported experiences—emerges as a critical indicator of the adequacy, continuity, and

quality of care provided in situations of complex chronicity.²˒¹²

The OECD and the WHO emphasise that this complexity translates into care trajectories marked by multiple

transitions between levels of care, a high therapeutic burden, and an increased risk of fragmentation, particularly

when systems remain organised around episodic, disease-centred logics.⁴˒⁵ According to recent OECD

admissions, duplication of procedures, and preventable suffering for people (and family caregivers) who

primarily require continuity, predictability, and close follow-up.¹³ It is therefore unsurprising that unplanned

hospital admissions have increased in recent years, with social and economic costs.²˒³

Within this framework, international guidance converges on the defence of person-centred care models

oriented towards coordination, integration, and longitudinal follow-up across disease trajectories.⁴˒¹³˒¹⁴ It is in

this domain that advanced nursing practice—and particularly the intervention of the nurse case manager—

assumes outstanding relevance. Scientific evidence demonstrates that nurses with advanced competencies in

holistic and systematic assessment, formulation of diagnoses centred on the person’s needs, clinical

coordination, organisational liaison and the development of sustained therapeutic relationships are particularly

well positioned to recognise suffering, understand the impact of illness on daily life, identify available resources

In Portugal, the nurse-to-population ratio per 1,000 inhabitants remains below the OECD average, and

investment in prevention and primary care continues to be limited.² In this context, organisational strategies

oriented towards care coordination and integration, such as case management, have been associated in the

scientific literature with gains in efficiency and value in health, particularly through care reorganisation.¹⁶˒²⁰

International reports underline that people’s satisfaction with health services is strongly associated with

perceived health status and the quality of communication.² In this domain, professionals with coordination and

longitudinal follow-up roles, such as nurse case managers, play a particularly relevant role by empowering

people with chronic illness to understand their condition, recognise warning signs, manage complex therapeutic

regimens and participate in informed decision-making about their care, in line with the principles of person-

territorial experiences, including the Alentejo Coast.³˒²⁰ However, RADIS data and OECD reports show that

care fragmentation and the inadequacy of organisational models for chronicity constitute structural and

persistent problems, requiring equally structural and sustained responses.²˒³

Within this framework, the formal integration of the nurse case manager into care models for people living

with chronic conditions—across primary, hospital and continuing care—aligns with the principles of person-

centred care; with the transition from acute episode-oriented models to trajectory-based approaches; with a

focus on prevention and chronic disease management; and with the promotion of greater territorial and social

Available evidence clearly demonstrates that traditional care models remain misaligned with the complexity of

chronicity. Person-centred care, coordination, and the longitudinal organisation of care are recognised as

across different care settings.

In a health system under pressure from ageing, multimorbidity, and finite resources, persisting with acute

episode-oriented responses perpetuates a widely recognised misalignment. By reorganising care pathways and

strengthening longitudinal coordination, nurse-led case management constitutes a response with demonstrated

impact on health system efficiency, contributing to reduced unplanned service use, more rational resource

allocation and value creation in contexts of complex chronicity.

Case Management; Nurse Case Manager; Chronic Disease; Multimorbidity; Continuity of Patient Care; Patient-

Centered Care.

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2 OECD. Health at a glance 2025: OECD indicators. [Internet]. Paris: OECD Publishing; 2025 [citado 2025 dez

30]. Available from: https://doi.org/10.1787/8f9e3f98-en.

3 Convenção Nacional de Saúde. RADIS 2025: Relatório de avaliação de desempenho e impacto do sistema de

saúde [Internet]. Lisboa: CNS; 2025 [citado 2025 dez 30]. Available

health care: transforming vision into action [Internet]. Geneva: World Health Organization; 2020 [citado 2025

dez 30]. Available from: https://www.who.int/publications/i/item/9789240017832

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[Internet]. 2017 [citado 2025 dez 30];32(10):1141-5. Available from: https://doi.org/10.1007/s11606-017-

8 Porter T, Ong BN, Sanders T. Living with multimorbidity? The lived experience of multiple chronic conditions

in later life. Health [Internet]. 2020 [citado 2025 dez 30];24(6):701–718. Available from:

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admissions for ambulatory care sensitive conditions: cross sectional study of routinely collected, person level

data. BMJ [Internet]. 2017 [citado 2025 dez 30];356:j84. Available from: https://doi.org/10.1136/bmj.j84

10 Wang N, Chen J, Chen W, Shi Z, Yang H, Liu P et al. The effectiveness of case management for cancer patients: