Postoperative pain management after hospital discharge remains one of the main clinical challenges. The use of digital and telemedicine tools offers new opportunities for the continuous monitoring of, and timely intervention in, patients discharged and followed at home. This scoping review, conducted according to the PRISMA-ScR checklist and the Joanna Briggs Institute methodology, analyzed 26 studies selected through a search of PubMed, Scopus, and Web of Science databases. Inclusion criteria comprised studies published between 2015 and 2025 that involved patients discharged home after surgery, that used digital or telemedicine tools for pain management, and that included active involvement of healthcare professionals and reported clinical outcomes. Studies show the use of a variety of digital tools, including mobile applications, web platforms, wearable sensors, automated messaging systems, and virtual reality technologies, alternating across settings for the assessment and management of pain at home, educational and therapeutic support, and to enhance communication between healthcare professionals and patients. Most reported outcomes focus on improved home-based pain control, a reduction in opioid consumption, and a high level of patient satisfaction. However, some challenges remain, particularly the low level of digital literacy among certain segments of the population. In conclusion, the implementation of telemedicine and digital technologies for managing postoperative pain at home proves to be a promising strategy. Nonetheless, it requires further scientific investigation and, from policymakers, significant investments in professional training and technological infrastructure to ensure an increasingly equitable and sustainable distribution of home healthcare services.

Background and Objectives: One of the challenges of modern healthcare systems, in terms of economic and organizational sustainability and the impact on patients’ quality of life, is the progressive increase in chronicity and care complexity. In this scenario, hospital–community integration models represent possible strategies to ensure the continuity of care, reduce readmission rates, and improve clinical outcomes. This study aims to map integrated care models for patients with chronic diseases, with active involvement of the family and community nurse, describing their functions and associated clinical, organizational, and economic outcomes, as well as barriers and facilitators to their implementation. Materials and Methods: The review was conducted using the JBI methodology and the PRISMA-ScR protocol and identified 26 studies with a publication range from 2000 to 2025. Results: The emerging results highlight the use of integrated and personalized organizational models in the post-discharge phases, with a leading role for the family and community nurse in the assessment, planning, and coordination of various steps. Conclusions: The interventions are associated with an increase in patient and caregiver satisfaction, a reduction in outcomes such as the rehospitalization rate, and greater continuity of care.

Chronic diseases represent one of the most complex, costly, and significant challenges for healthcare systems. The increase in chronic conditions and multimorbidity, together with the growing demand for continuity of care makes the vulnerability of the hospital-to-community transition increasingly evident. This phase is often characterized by delays, fragmented services, and insufficient support for patients and caregivers, leading to higher rates of early readmission and substantial clinical, social, and economic impacts. This paper was developed through a narrative synthesis of international and national literature on continuity of care, integrated models, and nurse-led experiences. Based on this synthesis, an integrated six-phase nursing model is proposed, combining predictive assessment tools and telemedicine to enhance early risk identification, proactive discharge planning, and post-discharge follow-up. Evidence indicates that nurse-led interventions supported by digital solutions can reduce inappropriate hospital days, decrease hospital readmissions, and improve patient and caregiver satisfaction. The integration of predictive tools and telemedicine solutions, coordinated by nurse case managers, represents a promising strategy to strengthen continuity of care and the sustainability of the healthcare system, and the proposed conceptual model highlights practical implications while outlining future research directions for empirical validation and large-scale implementation.

Background and Objectives: Thirty-day hospital readmissions are a major clinical and economic challenge, particularly among frail older patients. Integrated protected discharge models, coordinated by nurse case managers and including multidimensional hospital-to-community interventions, may improve continuity of care and reduce inappropriate readmissions. Materials and Methods: We conducted a retrospective observational study on 200 consecutive patients aged ≥65 years, discharged between January and December 2024 from a public hospital in Italy. Frailty was assessed using BRASS scores (≥11), ADL, and IADL. The primary outcome was 30-day hospital readmission. Logistic regression models evaluated the impact of individual interventions (Model 1) and combined interventions (Model 2), defined as the simultaneous presence of four components: nurse case manager involvement, telephone follow-up, activation of home care (ADI) within 24 h, and social worker support. Results: Overall, 65 patients (32.5%) were readmitted within 30 days. In the multivariate analysis, nurse case manager involvement was associated with lower odds of readmission (OR = 0.023; 95% CI 0.008–0.064; p < 0.001). Early ADI activation was not associated with readmission in the bivariate analysis (p = 0.195) but showed higher odds of readmission in the multivariable model (OR = 3.475; 95% CI 1.384–8.725; p = 0.008). The combined interventions variable was significantly associated with readmission in Model 2. Patients who did not receive combined interventions had higher odds of 30-day hospital readmission compared with those who did (OR = 26.1; 95% CI 10.1–67.5; p < 0.001). Conclusions: An integrated protected discharge model coordinated by a nurse case manager and including combined interventions was associated with lower odds of 30-day hospital readmission among frail older patients. These findings suggest that the potential benefit of transitional care may lie not in isolated interventions but in the multidimensional integration and coordination of clinical, functional, and social support strategies, highlighting the central role of nurse case managers in transitional care pathways.

Background and Objectives: Immunosenescence is a complex biological process associated with aging, characterized by a progressive decline in immune function and increased chronic inflammation (“inflammaging”), with clinical implications such as frailty, functional decline, multimorbidity, and a higher risk of adverse events in older adults. Nurses in community and primary care settings play a central role in preventive and health promotion interventions that may indirectly influence these processes. However, the available literature remains fragmented. Therefore, this scoping review aims to map and synthesise nursing interventions targeting older adults (≥60 years) that may indirectly influence immunosenescence by acting on its clinical correlates and modifiable determinants, organising the evidence within a four-pillar conceptual framework. Materials and Methods: A scoping review was conducted following JBI methodology and the PRISMA-ScR checklist. We included primary studies on nurse-led interventions in community, home care, primary care, territorial, or long-term care settings. PubMed, Scopus, and Web of Science were searched (English; last 10 years). Interventions were classified into four pillars: nursing nutrition and immunonutrition support, physical activity and exercise support, nursing vaccination coaching, and frailty monitoring and prevention of functional decline. Results: Twenty-five primary studies were included, mostly randomised or cluster-randomised trials in community, primary care, home care, and transitional care settings. Interventions mapped mainly to Pillar 4 and Pillar 2, while Pillar 1 was less frequent and usually part of multicomponent programmes; no primary studies targeted Pillar 3. Overall, effectiveness appeared driven more by intervention intensity and integration than by frailty identification alone: structured, multicomponent nurse-led programmes combining exercise with nutritional and psychosocial components showed the most consistent benefits on frailty, functional outcomes, and well-being, whereas low-intensity preventive consultations and Comprehensive Geriatric Assessment (CGA)-based models often showed limited improvements over usual care. Conclusions: This scoping review highlights the key role of community and primary care nurses in preventive interventions targeting clinical correlates of immunosenescence. Multicomponent nurse-led programmes integrating physical activity, nutrition, and psychosocial support appear most promising for frailty and functional outcomes, while low-intensity interventions show limited effectiveness. No primary studies addressed nurse-led vaccination coaching, representing an evidence gap. Future research should include biological/immunological markers alongside clinical outcomes.

Background: Multiple sclerosis (MS) is a condition that requires long-term, multidisciplinary management. The growing digital transformation in healthcare has highlighted the central role of nurses in supporting key aspects such as patient self-management, continuity of (at home) care, and patient empowerment. However, evidence on nurse-led digital interventions in MS remains fragmented. Objective: To map the available literature on nurse-led digital interventions in MS, focusing on the role of nurses, clinical outcomes, and research gaps. Methods: The review was conducted using the methodological framework of the Joanna Briggs Institute (JBI) and the PRISMA-ScR checklist. A systematic search was performed in PubMed, Scopus, Web of Science, and CINAHL. Studies were included if they described digital or telehealth interventions led or coordinated by nurses in patients with MS. Results: A total of 12 studies published between 2015 and 2025 met the inclusion criteria. Four main thematic areas were identified: (1) telenursing and empowerment-based interventions; (2) mobile and web-based patient self-management programs; (3) digital systems for monitoring and integrated care pathways; and (4) digital interventions targeting symptom management and psychosocial outcomes. Across the studies, nurse-led digital interventions were associated with improvements in self-management, treatment adherence, self-efficacy, and health-promoting behaviors. Positive effects were also reported on clinical outcomes such as fatigue, sleep quality, and balance, as well as on psychosocial variables including quality of life, coping strategies, and emotional well-being. Furthermore, the identified systems, in general, contributed to enhanced continuity of care, patient engagement, and organizational efficiency. Conclusions: Nurse-led digital interventions represent a promising approach in the management of patients with multiple sclerosis, supporting both clinical and psychosocial outcomes while enhancing continuity of care. However, the current evidence base remains limited by small sample sizes, heterogeneity of interventions, and short follow-up periods. Future research should prioritize multicenter randomized studies with larger samples and long-term follow-up to strengthen the evidence. Additionally, the integration of digital interventions into routine clinical practice, along with targeted training for nurses, is essential to ensure sustainability, accessibility, and equitable implementation. Further studies should also explore cost-effectiveness and the impact on caregivers and long-term quality of life.