According to a world health organization (WHO) report, chronic diseases annually kill over 35 million people worldwide, and 80% of those chronic disease related deaths occur in low and middle income countries. Increased incidence of chronic disease in Iran is a cause of re-hospitalizations and economic burden. Using a new nursing care model for patients with chronic disease is a strategy to reduce re-hospitalization of these patients, increase patient satisfaction and improve the outcome for patients with specific conditions. The aim of this study was to review and introduce a transitional care model (TCM) as a new nursing care model for management of patients with chronic conditions. Innovations relating to the nursing practice and delivery of care as a transitional care model for patients with chronic conditions are being implemented in many countries, to produce new forms of health care models.  The aim of these new care models is to reduce the after-care gap for patients with chronic conditions, and deliver long term care for them after discharge from the hospital.


Keywords: Chronic conditions, Long term care, Liaison nurse, Transitional care model
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