title: A structured review of chronic care model components supporting transition between healthcare service delivery types for older people with multiple chronic diseases.
abstract: 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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: 1 Queensland University of Technology, Australia.
authors.forename: Marguerite
authors.initials: M
authors.lastname: Sendall
authors.affiliation: 1 Queensland University of Technology, Australia.
authors.forename: Laura
authors.initials: L
authors.lastname: McCosker
authors.affiliation: 1 Queensland University of Technology, Australia.
authors.forename: Kristie
authors.initials: K
authors.lastname: Crossley
authors.affiliation: 1 Queensland University of Technology, Australia.|2 University of Queensland, Australia.|3 Royal Brisbane and Women's Hospital, Australia.
authors.forename: Ann
authors.initials: A
authors.lastname: Bonner
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D006301:Health Services Needs and Demand; D006801:Humans; D000071069:Multiple Chronic Conditions / Q000628:therapy*; D000069341:Transitional Care
keywords: CCM; ambulatory; chronic care model; chronic disease; clinical continuity of patient care; decision support systems; elderly; information systems; older people