Background: Longer average life expectancies have caused the rapid growth of the elderly as a percentage of Taiwan's population and, as a result of the number of elders with chronic diseases and disability. Providing continuing-care services in community settings for elderly with multiple chronic conditions has become an urgent need. Purpose: To review the nurse-led care models that are currently practiced among elders with chronic disease in the community and to further examine the effectiveness and essential components of these models using a systematic review method. Methods: Twelve original articles on chronic disease-care planning for the elderly or on nurse-led care management interventions that were published between 2000 and 2015 in any of five electronic databases: MEDLINE, PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature) Plus with Full Text, Cochrane Library, and CEPS (Chinese Electronic Periodicals Service) were selected and analyzed systematically. Results: Four types of nurse-led community care models, including primary healthcare, secondary prevention care, cross-boundary models, and case management, were identified. Chronic disease-care planning, case management, and disease self-management were found to be the essential components of the services that were provided. The care models used systematic processes to conduct assessment, planning, implementation, coordination, and follow-up activities as well as to deliver services and to evaluate disease status. The results revealed that providing continuing-care services through the nurse-led community chronic disease-care model and cross-boundary model enhanced the ability of the elderly to self-manage their chronic diseases, improved healthcare referrals, provided holistic care, and maximized resource utilization efficacy. Conclusions/Implications for Practice: The present study cross-referenced all reviewed articles in terms of target clients, content, intervention, measurements, and outcome indicators. Study results may be referenced in future implementations of nurse-led community care models as well as in future research.
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