OPTIMIZING CHRONIC DISEASE MANAGEMENT THROUGH INTEGRATED CARE: THE ROLE OF NURSES, PHARMACISTS, AND NUTRITIONISTS
Main Article Content
Keywords
Integrated care, chronic disease management, nurses, pharmacists, nutritionists, adherence, hospital readmissions, quality of life.
Abstract
Background: Chronic diseases such as diabetes, heart failure, and chronic kidney disease are leading causes of morbidity and mortality worldwide. Fragmented, siloed care pathways contribute to poor adherence, frequent hospital readmissions, and reduced quality of life. Integrated care models involving nurses, pharmacists, and nutritionists have emerged as promising approaches to address these challenges.
Objective: To synthesize evidence on the impact of multidisciplinary care involving nurses, pharmacists, and nutritionists in optimizing chronic disease management, with a focus on adherence, readmissions, and quality of life outcomes.
Methods: A narrative review of literature published from 2018 to 2025 was conducted using PubMed Central, Google Scholar, and institutional repositories. Priority was given to randomized controlled trials, systematic reviews, and consensus guidelines. Outcomes of interest included HbA1c reduction, blood pressure control, hospitalization rates, and quality-of-life measures. Quantitative results were extracted, summarized in tables and figures, and a network diagram illustrated team interactions.
Results: Nurse-led interventions reduced hospital readmissions in heart failure (25.5% → 5.6%) and improved glycemic control in diabetes (HbA1c 7.92% → 6.94%, P < 0.01). Pharmacist-led programmes lowered hospital admissions (0.78 → 0.54, P < 0.001), improved medication adherence, and decreased systolic blood pressure by ~6.8 mmHg. Nutritionist-delivered medical nutrition therapy reduced HbA1c by up to 2.0% in type 2 diabetes and slowed CKD progression, while also addressing dietary-related risk factors for heart failure readmissions. Integrated multidisciplinary models demonstrated enhanced patient satisfaction, improved self-management behaviors, and overall cost savings.
Conclusions: Integrated care uniting nurses, pharmacists, and nutritionists significantly improves clinical outcomes, reduces readmissions, and enhances quality of life in patients with chronic diseases. Broader implementation requires addressing policy barriers, workforce training, reimbursement challenges, and equity in access.
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Sulaiman Nasser S Alduayji
Nutrition Services department, Qassim Armed Forces Hospital (QAFH) — Buraidah, Qassim, Saudi Arabia.
Omar Abdullah Alowaymir
Nutrition Services department, Qassim Armed Forces Hospital (QAFH) — Buraidah, Qassim, Saudi Arabia.
Mubarak Zaben Al anazi
Pharmaceutical Care department, Qassim Armed Forces Hospital (QAFH) — Buraidah, Qassim, Saudi Arabia.
Meshal Salah Mohammed Alharbi
Pharmaceutical Care department, Qassim Armed Forces Hospital (QAFH) — Buraidah, Qassim, Saudi Arabia.
Sulaiman Faihan Salem Alharbi
Pharmaceutical Care department, Qassim Armed Forces Hospital (QAFH) — Buraidah, Qassim, Saudi Arabia.
Abdullah Namer Alotaibi
Nursing department, Qassim Armed Forces Hospital (QAFH) — Buraidah, Qassim, Saudi Arabia.