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Literature Review | | References
AMDA Long Term Care Guidelines Click Here note:(large file please be patient)
Craig C, Eby D, Whittington J. Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 201 Click here
Council on Aging
Akron/Canton Area Agency on Aging
Regional Community-Based Care Transitions Program Click here
Atlanta Community Based Care Transitions Program Click here
Healing@Home Area Agency on Aging, Region One Click here
Merrimack Valley Care Transitions:
A Collaborative Approach Regional Community-Based Care Transitions Program Click here
Southwest Ohio Community Care Transitions Collaborative Click here
Berkowitz, R. et al. (2011). Improving Disposition Outcomes for Patients in a Geritric Skilled Nursing Facilty. Journal of the American Geriatrics Society. 59:1130-1136. Click here
Boutwell, A. et al. (2011). An Early Look at a Four-State Initiative to Reduce Avoidable Hospital Readmissions. Health Affairs. 30, No.7:1272-1280. Click here
Coleman, E. et al. (2005) Post Hospital Mediciation Discrepancies: Prevalence and Contributing Factors. Archives of Internal Medicine. Vol 165, Sep 12. Click here
Cunningham, P., Sommers, A., (2011). Physician Visits After Hospital Discharge: Implications for Reducing Readmissions, National Institute for Healthcare Reform., Number 6, Dec. 2011. Click here
Dedhia,Param, et al., (2009). A Quality Improvement Intervention to Facilitate the Transition of Older Adults from Three Hospitals Back to Their Homes. 57:1540-1546. Click here
Epstein, Arnold, M., MD., Jha, Ashick,K., MD.,MPH., Orav, E., John, PH.D. The Relationship between Hospital Admission Rates and Rehospitalizations. New England Journal of Medicine2011; 365: 2287-95. Click here
Gawandi, Atul. January 24, 2011. Hot Spotters. The New Yorker. Click here
Gottlieb, Sylvester and Eby. Transforming Your Practice: What Matters Most. Family Practice Management. www.aafp.org/fpm. January 2008 Click here
Ha, A. et al. (2009). Public Reporting of Discharge Planning and Rates of Readmissions. New England Journal of Medicine. 361;27. December 31. Click here
Health Care Leader Guide to Reduce Avoidable Readmissions. Commonwealth Fund, The John Hartford Foundation and the Health Research & Educational Trust. January 2010. Click here
Jencks S, Williams M, Coleman E., (2009). Rehospitalizations Among Patients in the Medicare Fee-for-Service Program. New England Journal of Medicine. 360:1418-28. Click here
Improving Transitions of Care. September 2010. National Transitions of Care Coalition. (NTOCC) Click here
Lourde, Kathleen. (2011). Ramping up for Higher Acuity. Nursing Facilities Respond to the Need for Reducing Hospitalizations. Provider. January. Click here
Mor, V, et al. (2010) The Revolving Door of Rehospitalizations from Skilled Nursing Facilities. Health Affairs. 222999, No.1 :57-64. Click here
McCarthy, D., Klein, S. The Triple Aim: Journey: Improving Population Health and Patients’ Experience of Care, While Reducing Costs. Commonwealth Fund pub. 1421. Vol. 48. Click here
Naylor, M., Sochalski. (2010) Scaling Up: Bringing the Transitional Care Model into Mainstream. Issue Brief. Commonwealth Fund pub. 1453. Vol. 103. Click here
Ouslander, J. et al. (2011) Interventions to reduce Hospitalizations from Nursing Homes: Evaluation of the INTERACT II Collaborative Quality Improvement Project. Journal of the American Geriatrics Society. 59:745-753. Click here
Patient-Centered Primary Care Collaborative (PCPCC). Core Value, Community Connections: Care Coordination in the Medical Home Click here
Predicting non-elective hospital readmissions: A multi-site study. Journal of Clinical Epidemiology. 53(11):1113-1118. Click here
Rutherford P,Nielsen GA, Taylor, J, Bradke P, Coleman, E. How-to –Guide: Improving Transitions from the Hospital to Post-Acute Care Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement. June 2011. Available at www.IHI.org.
Sanghavi, Darshak. The Phantom Menace of Sleep Deprived Doctors. August 5, 2011. The New York Times. Click here
Sommers, Anna, Cunningham, Peter J. (2011). Physician Visits After Hospital Discharge: Implications for Reducing Readmissions. National Institute for Health Care Reform. Research Brief Number 6. December 2011. Click here
Steele, G. et al. (2010) How Geisinger’s Advanced Medical Home Model Argues the Case for Rapid-Cycle Innovation. Health Affairs. 29:11. Click here
Sharma, G. et al. (2009) Continuity of outpatient and Inpatient Care by Primary Care Physicians for Hospitalized Older Adults. Journal of the American Medical Association. Vol 301, No. 16:1671-1680. Click here
Silow-Carroll, Edwards, J. Intermountain Healthcare’s McKay-Dee Hospital Center: Driving Down Readmissions by Caring for Patients the “Right Way”. Commonwealth Fund pub. 1769. Volume 1. Click here
Soeken K, Prescott P. (1991). Patient Intensity for nursing index: The measurement tool. Research in Nursing and Health. 14(4):297-304. Click here
The Post-Hospital Follow-up Visit: A Physician Checklist to Reduce Readmissions. California HealthCare Foundation. Issue Brief. October 2010. Click here
Web References
Society of Hospital Medicine - Project BOOST
Better Outcomes for Older Adults through Safe Transitions Click here(Project Boost)
The Commonwealth Fund - A Private Foundation Working Toward a High Performance Health System. Click here
The Hospital to Home (H2H) initiative Click here
Institute for Healthcare Improvement Click here
Interventions to Reduce Acute Care Transfers Click here
The Chronic Care Model - Robert Wood Johnson Foundation Click here
National Transitions of Care Coalition Click here
The Remington Report - The Healthcare Magazine for Executives Click here
The Transitional Care Model Click here
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