Modelo de cuidados integrados: transição de cuidados agudos para crônicos

O Modelo de Cuidados Integrados (ICM) tem duas categorias principais: Modelo individual e Modelo específico para grupos e doenças. Primeiro, é usado para pacientes de alto risco e / ou com várias doenças. Na segunda categoria; O Modelo de Cuidado Crônico (CCM) é a forma mais conhecida de Modelo de Cuidados Integrados para melhorar os resultados em pacientes com condição crônica, para passar do cuidado agudo para a enfermagem integrada, regular, duradoura, preventiva e baseada na comunidade.

Considerações finais:

É importante considerar o paciente como um membro ativo da equipe de tratamento. Parece ser essencial monitorar o desempenho do sistema de atendimento. Por outro lado, oferecer assistência multidisciplinar leva a apresentar cuidados desejáveis, adequados às necessidades específicas dos pacientes quanto à segurança, ao cuidado centrado no paciente e à sua cultura.

Descritores:
Cuidados de Longo Prazo; Planejamento Avançado de Cuidados; Modelos de Enfermagem; Organização Mundial da Saúde; Enfermeiros

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.

Associação Brasileira de Enfermagem SGA Norte Quadra 603 Conj. "B" - Av. L2 Norte 70830-102 Brasília, DF, Brasil, Tel.: (55 61) 3226-0653, Fax: (55 61) 3225-4473 - Brasília - DF - Brazil
E-mail: reben@abennacional.org.br

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