Problem

A growing body of science suggests that patients coping with multiple chronic conditions or complex therapies are particularly vulnerable to breakdowns in care. During the last four to five decades, the leading causes of death have changed from infectious and acute diseases to chronic and degenerative illnesses including cardiovascular diseases and cancer, respiratory diseases and injuries, diabetes and Alzheimer’s disease .These conditions also cause severe disability and is a common factor leading to the need for long-term aftercare(1). Insufficient communication between providers in health care agencies and patients, inadequate patient education, poor continuity of care, and limited access to health services especially after discharge from the hospitals, are the major factors contributing to negative patient care quality and cost outcomes. Re-hospitalization rates for these patients are very high and it is cause of burden cost for patient and hospital. Also, Since the 1960s there has been an awareness of 'care-gap' when patients are transferred between hospital and home. Today in reviewing of nursing services, we find increasing emphasis on the patient as a person and on hospitalization as only one phase in his total care. An acceptance of this concept extends responsibility for nursing services beyond the hospital in to the home and from the home to the hospital without any break in its continuity .in other words, nurses must deliver health care services, since early hospitalization of the patients and during the hospitalization, also deliver aftercare since discharge of the patients and referring to their homes. In the United Kingdom, attempts to improve continuity of care have included the development of the role of the hospital liaison nurse. nurses who work in general hospital setting do not generally consider themselves adequately prepared, skilled or experienced to care for patients with chronic disease or problems that need to aftercare at home. This issue not restricted to their skills or knowledge but also relates to their scope of practice. Instance, the research's results have shown that existence of the liaison nurse, as a new role, between hospital and patients home, have positive effects in patient outcomes. Therefore, regarding to the role of the liaison nurse in hospital, there is a hypothesis including: - Patients with chronic diseases, who are hospitalized under the new model of care that will be delivered by liaison nurse, would be better experiences and clinical outcomes (improve quality of life) than they had during previous hospitalizations prior to the implementation of the new model.

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