Nurses play a pivotal role in the care of chronic patients. In consequence, innovations relating to the nursing practice as a liaison nurse and care for chronic patients are being implemented in many countries to produce new forms of health care model. These innovations often aim to break care gap and deliver long term after care for chronic patients.  Long term after care means a shift of care givers responsibilities and tasks from hospital to patients home that qualitatively good care is provided by the most appropriate health care provider at the lowest cost level.

Implementing transitional care model show that it is indeed possible to decrease rates of re-hospitalization also duration of hospitalization of chronic patients. Patients and loved ones are better able to manage their care independently and their quality of life will be promoted. 

Improved coordination of care leads to better communication and improved satisfaction ratings between patients and healthcare providers. Also improve quality of care and decrease health care costs.

In this paper author try to introduces a new model of nursing care, especially in patients with chronic diseases that will full care gap between hospital and home. Also the author suggests the positive and effective role of the liaison nurse in promote of quality of life of the patients with chronic diseases in this new model of care.

Key words: Liaison Nurse; Transitional care model; Chronic patients; Long term care; Quality of life  
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