Objective: Older people with chronic diseases often have complex and interacting needs and require treatment and care from a wide range of professionals and services concurrently. This structured review will identify the components of the chronic care model (CCM) required to support healthcare that transitions seamlessly between hospital and ambulatory settings for people over 65 years of age who have two or more chronic diseases. Method: A structured review was conducted by searching six electronic databases combining the terms ‘hospital’, ‘ambulatory’, ‘elderly’, ‘chronic disease’ and ‘integration/seamless’. Four articles meeting the inclusion criteria were included in the review. Study setting, objectives, design, population, intervention, CCM components, outcomes and results were extracted and a process of descriptive synthesis applied. Results and conclusion: All four studies reported only using a few components of the CCM – such as clinical information sharing, community linkages and supported self-management – to create an integrated health system. The implementation of these components in a health service seemed to improve the seamless transition between hospital and ambulatory settings, health outcomes and patient experiences. Further research is required to explore the effect of implementing all CCM components to support transition of care between hospital and ambulatory services.
From concept to content: assessing the implementation fidelity of a chronic care model for frail, older people who live at home
