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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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