Integrated Care model: Transition from acute to chronic care

Objective: Description and discussion dimensions of Integrated Care Model. Methods: A descriptive study is done that describe a technological innovation, intervention strategies for professional performance. Results: 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 Planning; Nursing Models; World Health Nurses.


INTRODUCTION
The integrated care model is introduced by the World Health Organization (WHO), that is used to improve resultants of care in patients' condition by integrated, regular, long-lasting and societybased nursing. According to the evidence, the resultants obtained from this model were desirable to make the caring qualities preferment and costs parsimony (1) . Regarding this model credibility and its opportune in situations that patient is in transition from acute to chronic condition and because it's unknown for nurses, we will discuss dimensions and benefits of this model briefly.

Integrated Care Model
Integrated care model is used opposed to fragmentarycare and for once care and synonymous with coordinated care or seamless care (2) . Integrated care includes continuous process. The World Health Organization defined an integrated care model as people-based care during the life regarding multi-dimensions; this care is given by multi-disciplinary team in various settings and various care levels. This care needs to effectively manage and use credible resources based to present evidence, is also aligned to the feedback continuums to ensure about the quality of the care. It could be planned limited to hospitalization period or for the whole life of the patient in chronic cases (1) . The viewpoints make the concept are built by outlook and expectancy of different stakeholders in the medical team ( Figure 1).

Models of integrated care
There are various models to offer integrated care that is mentioned in two main categories:

Individual integrated care model
This model is used for risky patients or with comorbidities and caregivers, thus it prevents to discontinuity in the care by different caregivers. Also, thus care to the patient will not be one episodic, but it can be done across the life-course. This model fits the patients who go to the hospital a lot, so care can be done in the house. The services include evaluation of the patient and giving care if it is necessary, regular patient visit and set a care plan. Although this model reduces the looking up to the hospital, but might not be economical in terms of costs.

Group-and disease-specific Model
In this Category, Chronic Care Model(CCM), is common and used form of integrated care model, CCM was first developed in 1998 by MacColl Institute in USA (3) . Chronic Care Model(CCM) is used to improve resultants in the patients with the chronic condition. This model proposes to move from acute and reactive care to integrate, regular, long-lasting, preventative and community-based nursing. According to the evidence, the resultants obtained from this model were desirable and qualified care, also better in patient's outcomes and costs parsimony for patients. It also affirms to offer patient safety, regarding culture and special needs focused care (Figure 2).

METHODS
A descriptive study is done that describe a technological innovation, intervention strategies for professional performance.
This model includes six main dimensions: Community, Health System, Health Management Support, Delivery system design, Decision Support and Clinical Information system. In the revised version, cultural adaptability, considering community policies, coordination in giving care is added to the model (1) (Chart1).

DISCUSSION
Reviewing relevant studies in term of chronic and long term conditions, showed that the most used model is chronic care model of the integrated care model; which is appropriate for various conditions include transition from acute to chronic heart failure (4) , re-integration to normal life in patients following upper extremity amputation (5) , care of stroke and patients with transient ischemic attack (6) , patients with Multimorbidity (7) , case management of patients care at home (8) , chronic kidney disease patients (9) and patients with chronic obstructive pulmonary disease(COPD) (10) .
In this model, it is important to consider patient as key member of the medical team. It seems to be essential to supervise  function of clinical team and care system. On other hand, offer multidisciplinary care leads to present desirable care, tailored to the specific needs of patients by defining the role of each person in team, regarding safety, patient-centered care and according to patient culture. Eventually, the given care plan is appropriate for patients in their own culture.

FINAL CONSIDERATIONS
Multidisciplinary care with considering patients as an active member of the treatment team, according to patient culture tailored to the specific needs.