Nurse 'case managers' in oncology, continuous and timely care even at home

In health care we often speak of innovation thinking of technologies, drugs or equipment, but one of the most profound innovations concerns the organisation of care and the way in which the health care system really takes care of people. Starting from this conviction, at the Mauriziano Hospital in Turin we have introduced into our daily clinical-assistance practice a figure that is still not widespread in our country but is destined to become central: the case manager nurse.

It is a professional with advanced training who accompanies the cancer patient throughout the entire course of treatment: from the moment of diagnosis, to admission, and up to 30 days after discharge. Always the same person, the same face, the same voice on the phone when a clarification is needed or a critical issue arises. It is not just a coordination function. The case manager is a professional who enters directly into the care relationship, intercepts the patient's and family's needs, facilitates dialogue between specialists and services, and helps navigate between visits, therapies and decisions. In other words, he/she guarantees continuity of care and relationships in a pathway that, especially in oncology, is often complex and fragmented.

The model is inspired by and forms part of the Fundamentals of Care (FoC) implementation programme initiated by the company in collaboration with the University of Genoa. This is an increasingly central international reference for the evolution of nursing care. This approach explicitly integrates the clinical, relational and psychosocial dimensions of care, overcoming a purely performance-based vision of care. The project was launched at the Mauriziano on the initiative of Alessio Rizzo, Head of Organisational and Professional Development in the Health Professions Directorate, and Antonio Valenti, in oncological surgery, with the aim of introducing a care approach capable of guaranteeing real continuity between the hospital, the treatment pathway and the patient's home.

In our hospital, we are no longer talking about an experiment, but about a consolidated organisational model, with a network of seven nurse and obstetrician case managers active in oncology pathways and, in general, in areas of high complexity, both in the medical and surgical areas. An experience that has received several awards including, recently, the Cipomo 'Elisabetta Fabbrini' 2026 National Prize, awarded to the best organisational innovation projects in oncology, in collaboration with the Federation of Healthcare and Hospital Companies (Fiaso) and the Federation of Nursing Professions Orders (Fnopi).

The monitoring data, covering the last six months and used to make the results tangible, concern three case managers, working in the oncology pathways (Medical Oncology, Breast Unit and Oncology Surgery) and show significant results. During the period analysed, 336 patients were followed up by case managers, with timely intake in 97.4% of cases and continuity of care after discharge in 94% of patients. More than 90% of the persons were discharged home without the need for further healthcare support, thanks to the preparation of the patient and family during admission and active follow-up after returning home. Proactive follow-up also allows early interception of possible complications: in oncology patients followed with this model, there were no unplanned admissions to the emergency department within 30 days, while readmissions were very low in surgical pathways.