Integrated Care model: Transition from acute to chronic care

Integrated Care Model (ICM) has two main categories include individual and Group-and disease-specific Model. First, is used for risky patients or with comorbidities. In second category; Chronic Care Model (CCM) is common form of Integrated Care Model to improve resultants in the patients with chronic condition, to move from acute care to integrate, regular, long-lasting, preventative and community-based nursing.

Final considerations:

It is important to consider patient as an active member of the treatment team. It seems to be essential to monitor performance of care system. On the other hand, offer multidisciplinary care leads to present desirable care, tailored to the specific needs of patients regarding safety, patient-centered care and their culture.

Descriptors:
Long-Term Care; Advance Care Planning; Nursing Models; World Health Organization; Nurses

Domain	Objective/description	Strategies
Community	Moving communityresources to encounter needs of patients	Persuade patients for participation in efficient community plans; Form cooperation with community organizations to assistant interventions that fill gaps in needed servicesAdvocate policies to ameliorate patient care^* * Strategies that were added to the original Chronic Care Model after 2003 revision.
Health System	Develop culture, organizationand mechanisms ameliorate safe, high quality care	Help improvement at all levels of organization starting with senior leader; Increase effective strategies goal wide system change; Support open and systematic handling of errors and qualityproblems to ameliorate care^* * Strategies that were added to the original Chronic Care Model after 2003 revision.
Delivery System Design	Be sure delivery of effective , efficient clinical care support and self-management assistant	Introduce roles and tasks among members; Utilize planned interactions to assist evidence-based care ; Give clinical case management services for complicated patients^* * Strategies that were added to the original Chronic Care Model after 2003 revision. ; Be sure of constant follow-up by medical team ; Give care in understandable way for patients and according to their cultural
Self-management Support	Enable patients for managing their health status and health care	Accent patient's central role for managment their health status ; Use efficient self-management assistant strategies that includeassessment, goal-setting, action plann, problem-solving andfollow-up; Manage internal and resources in community for providing ongoing self-management support to patient
Decision Support	Improve clinical care that is according with last version of evidence and patient priorties	Using guidelines with evidence-based approach for every day clinical practice Give informations and evidence-based guidelines with patients tofacilitate participation; Use approved methods for education; Combine expertise of specialist and primary care
Clinical Information System	Arrange patients and data tohelp efficient and effective care	Plan schedule reminders for care provider and patient; Introduce relevant sub-populations for active care; Improve planning for patient care; View performance of clinical team and care system; Give data to patients and caregivers for harmonic care^* * Strategies that were added to the original Chronic Care Model after 2003 revision.

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[1] Corresponding Author: Pegah Matourypour E-mail: p-matourypour@sina.tums.ac.ir