An integRatEd framework for domiciliary healthcare SkillS development.

Spanish pilot


Castile Leon Map RegionalThe current demographic trend in Spain continues with its ageing process. On January 1, 2014 there were 8.442.427 old people (over 65), 18,1% of the total population (46.771.341) . This upward trend was even stronger (5,7%) in the case of octogenarians. Castilla y Leon is one of the most aged regions, with rates of over 20%.

Let’s consider the services portfolio of the Autonomous Region of Castilla y Leon as an example of the situation in Spain. We see that the primary healthcare system in this region provides scheduled care and ER, as well as home healthcare, which can be defined as the type of assistance or care provided in the home of the patients when they cannot visit the Outpatients Clinic due to their health condition or walking difficulty.

This services portfolio is not only provided to older adults. In fact, following the 2015 report presented by the National Health Services, home healthcare stands for 1,7% of the total family practice services provided -14 million visits per year. In the case of nurses the figure rises to 7,9%. The main users of this service are older adults of over 65 years of age, which account for 72% of all the homecare visits. We can conclude from these figures that almost three quarters of the homecare visits paid by nurses are to older adults. These patients be classified into four groups:

  • HEALTHY OLDER ADULTS: These patients do not have functional, social or mental problems. They just require sanitary instruction and assistance in their basic needs.
  • SICK OLDER ADULTS: They require help in being oriented in how to proceed in terms of their pathology.
  • FRAGILE OR AT HIGH RISK OLDER ADULTS: This is the group of older adults nurses spend more time with. They are usually independent in their basic everyday activities, but they are dependent for some instrumental everyday activities. They are generally patients of over 80 who hardly ever leave their homes or live in a nursing home. This isolates them socially and also from their families. They often have chronic pathologies, which condition their incapacity. They regularly take three or more pills.
  • GERIATRIC PATIENT: This type of patients are dependent both for their basic daily activities, and their instrumental daily activities. They often have multiple diseases co-occurring with one primary disorder which usually provokes their disability.

Thus, we may conclude that older adult homecare nurses provide different types of assistance:

  • Health care: Help older adults to be as independent as possible. And when this is not possible, older adults should be provided with the necessary assistance.
  • Social: Act as the link with social services.
  • Managing and administrative: Efficient organization of work and resources maximizing.
  • Educational: Instruct older adults, carers and family members in health issues.
  • Research: Scientific nursing production.



Providing home care to older adults and their family members to achieve a better health and wellbeing. Promoting positive attitudes towards their health needs and instructing them in the adoption of attention facilitation measures in the home environment. All this should be done within a sustainable and adequate project.


  • Identifying in order of priority the target older adult health problems.
  • Structuring and normalizing the user’s evaluation at home, through home care objective and subjective parameters. These parameters should guide professionals in their nursing diagnosis. Also, a care plan should be established.
  • Planning and evaluating the care needs of carers and its provision, reaching a compromise with family members.
  • Developing interpersonal communication abilities.
  • Training in sociosanitary coordination abilities through the knowledge of social, communitary and health team resources, as well as their functional connection. Services should be provided through multidisciplinary attention, considering older adults needs as one.
  • Respecting households, their habits and socioeconomic, cultural and religious environments, among others.
  • Guaranteeing different care provision levels, thus allowing a quick response to changes as well as a permanent communication system.
  • Handling tools for the efficient management of resources.
  • Adapting changes to content and complexity of home care provision, taking advantage of opportunities in treatment and supervision that technological advances provide.


  • Structuring and normalizing evaluation through home care objective and subjective parameters. These parameters should guide professionals in the older adult homebound diagnosis.
  • Evaluating the care needs of carers and its provision. 
  • Interpersonal communication abilities.
  • Sociosanitary coordination abilities.
  • Tools for the efficient management of resources.
  • Adapting to changes in content and complexity of home care provision, taking advantage of opportunities in treatment and supervision that technological advances provide.


Solving deficiencies found in general nurses competencies to be able to assist older adults at home. Creating a profile of nurse specialized in older adult homecare very useful for the current healthcare labor market.