Scanning the Headlines: Care Management (Archive) 2015-2014

Updated on June 6, 2016 

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Martsolf, G., Kandrack, R., and others.  (2015, Dec. 29).  Cost of Transformation Among Primary Care Practices Participating in a Medical Home Pilot.  Berlin, Germany:  Springer.  Retrieved from:

Role of Post-Acute Care in New Care Delivery Models.  Trendwatch.  (2015, Dec.).  Chcago:  AHA.

Addendum: Background On Post-Acute Care.  Trendwatch.  (2015, Dec.).  Chicago:  AHA.

(2015, Nov. 11).  Press Release:  New Study Shows Patient Centered Medical Homes Improve Health, Lower Costs.  Chicago:  Blue Cross Blue Shield.  Retrieved from:

Feorene, B.  (2015, Nov. 9).  The emergence of post-acute medicine.  H&HN.  Retrieved from:

Schwartz, A., Chemew, M., Landon, B., McWilliams, M.  (2015, Nov.).  Changes in low-value services in year 1 of the Medicare pioneer accountable care oganization program.  Journal of the American Medical Association (JAMA).  175(11):1815-1825.  Retrieved from:

Fingar, K., and Washington, R.  (2015, Nov.).  Trends in Hospital Readmissions for Four-High Volume Conditions, 2009-2013Statistical Brief #196.  Rockville, MD:  Agency for Healthcare Research and Quality.  Retrieved from:

Grube, M., Krishnaswamy, A., Poziemski, J., and York, R.  (2015, Nov.).  Identifying market and network opportunities for population health management. Health Facilities Management.  Retrieved from:

Commins, J.  (2015, Oct. 28).  Population health poses unique challenges in rural areas.  HealthLeaders Media.  Retrieved from:

Jha, A.  (2015, Oct. 27).  Seeking rational approaches to fixing hospital readmissions.  Journal of the American Medical Association (JAMA).  314(16):1681-1682.  Retrieved from:

(2015, Oct 16).  Transitional Care Interventions to Prevent Readmissions for People With Heart Failure.  Rockville, MD:  Agency for Healthcare Reseach and Quality.  Retrieved from:

Bradley, E., Brewster, A., and Curry, L.  (2015, Oct. 1).  National Campaigns to Reduce Readmissions:  What Have We Learned?  New York:  Commonwealth Fund.  Retrieved from:

Roberson, B.  (2015, Oct.).  The Hospital Readmissions Reduction Program:  Four Years of Data.  Washington:  Essential Hospitals Institute.  Retrieved from:

Pittman, P., and Forrest, E.  (2015, Sept.-Oct.).  The changing roles of registered nurses in pioneer accountable care organizations.  Nursing Outlook.  63(5):554-565.  Retrieved from:

(2015, Sept.).  Guide to Preventing Readmissions Among Racially and Ethnically Diverse Medicare Beneficiaries.  Baltimore, MD:  Centers for Medicare & Medicaid Services.  Retrieved from:

Overland, D.  (2015, July 30).  CareFirst's PCMH boots quality, lowers costs.  FierceHealthPayer.  Retrieved from:

Fellows, J.  (2015, July 23).  Investment in house calls for sickest patients pays off.  HealthLeaders Media

Letourneau, R.  (2015, July 20).  Orthopedics bundled payments are a classroom for value-based care.  HealthLeaders Media.  Retrieved from:

Erich, J. (2015, July 1). Kaiser Permanente's plan to prevent readmissions.  IH Executive. Retrieved from:

Kaplan R, Spittel M, David D (Eds). (2015, July).  Population Health: Behavioral and Social Science Insights. AHRQ Publication No. 15-0002. Rockville, MD: Agency for Healthcare Research and Quality and Office of Behavioral and Social Sciences Research, National Institutes of Health. 

Cunningham, P.J. (2015, July). Many Medicaid beneficiaries receive care consistent with attributes of patient-centered medical homes. Health Affairs, 34(7), 1105-1112. 

McDaniels, A.  (2015, June 29).  Hospitals save $100 million in Medicare costs.  Baltimore Sun.  Retrieved from:

Betbeze, P.  (2015, June 19).  Why you need both a pre-acute and post-acute presence.  HealthLeaders Media.  Retrieved from:

Coyle, C.  (2015, June 4).  Maryland results prove healthcare partnerships can improve care quality.  Hospital Impact. Retrieved from: 

Friedberg, M., Rosenthal, M., Werner, R., Volpp, K., Schneider, E.  (2015, June 1).  Effects of a medical home and shared savings intervention on quality and utilization of care.  Journal of the American Medical Association (JAMA).   Retrieved from:

Summer, L., Hoadley, J. (2015, June).  Early Insights from Commonwealth Coordinated Care:  Virginia’s Demonstration to Integrate Care and Align Financing for Dual Eligible Beneficiaries.  Kaiser Family Foundation Issue Brief. Retrieved from:

(2015, June).  Latest Evidence:  Benefits of the Patient-Centered Medical Home.  Washington:  National Committee for Quality Assurance.  Retrieved from:,%20June%202015.pdf

Mattke, S., Higgins, A., and Brook, R.  (2015, May 21).  Results from a national survey on chronic care management by health plans.  American Journal of Manged Care.  21(5):370-376.  Retrieved from:

(2015, May).  2014 Natonal Healthcare Quality and Disparities Report.  Chartbook on Care Coordination.  Rockville, MD:  Agency for Healthcare Research and Quality.  Retrieved from:

Zweig, D.  (2015, Apr. 22).  Aetna's oncology medical home will 'define the value of care'.  FierceHealthPayer.  Retrieved from:

Counsell, M.D., S.  (2015, Apr. 9).  A hybrid approach to avoiding readmissions.  H&HN.  Retrieved from:

Pines, M.D., J., Keyes, V., Hasselt, M., McCall, N.  (2015, Mar. 10).  Emergency department and inpatient hospital use by Medicare beneficiaries in patient-centered medical homes.  Annals of Emergency Medicine.  Retrieved from:

(2015, Mar).  Community need and readmissions.  HealthLeaders Media.  Retrieved from:

(2015, Mar.).  Colorado Critical Access Hospitals and Clinics:  Improving Communication and Readmission (iCARE) White Paper.  Milwaukee, WI:  iCARE.  Retrieved from:

(2015 Mar.).  Rethinking the Hospital Readmissions Reduction Program.  Chicago:  American Hospital Association.  Retrieved from:

Clark, C.  (2015, Feb. 4).  Most surgical readmissions caused by common complications.  Healthleaders Media.  Retrieved from:

Merkow, R., Ju, M., Chung, J., Hall, B., Cohen, M., Williams, M., Tsai, T.  (2015, Feb. 3).  Underlying reasons associated with hospital readmission following surgery in the United States.   Journal of American Medical Association (JAMA).  (313):483-495.  Retrieved from:

Hilligoss, B., and Vogus, T.  (2015, Feb.).  Navigating care transitions.  Medical Care Research and Review.  72(1):25-48.  Retrieved from:

Betbeze, P.  (2015, Jan. 23).  Pharmacist- led discharge program cuts readmissions 46%.  HealthLeaders Media.  Retreived from:

Commins, J.  (2015, January 20).  Execs upbeat on population health ROI.  HealthLeaders Media.  Retrieved from:

Private-Sector Hospital Discharge Tools.  (2015, January).  Chicago:  American Hospital Association, 2015.  Retrieved from:

Wiley, J., and others.  (2015, January).  Managing chronic illness: physician practices increased the use of care management and medical home processes.  Health Affairs.  34:178-86.  Retrieved from:

Cole, E., and others.  (2015, January).  Patient-centered medical homes in Louisiana had minimal impact on Medicaid population’s use of acute care and costs.  Health Affairs.  34:187-94.  Retrieved from:

(2015, January).  Theory Into practice:  Transitional Care Model's Success Demonstrates That Evidence Alone Isn't Enough.  Mount Laurel, NJ:  Commission for Case Manager Certification (CCMC).  Retrieved from:

Coffman, J.M. (2015, Jan.-Feb.). Engaging residents: A Wisconsin hospital makes its community stronger, one health initiative at a time. Healthcare Executive, 30(1), 58, 60-61.

(2015).  Coordination of Care and the Patient Experience.  South Bend:  Institute for Innovation.  Retrieved from:

Haran, C.  (2015).  Improving Care for Those Who Need It Most.  New York:  Commonwealth Fund.  Retrieved from:

Wizemann, T., and Thompson, D.  (2015).  Spread, Scale, and Sustainability in Population Health.  Washington:  National Academies Press.  Retrieved from:

Lifsey, S., Cash, A., Anthony, J., Mathis, S., Silva, S.  (2015).  Building the evidence base for population-level interventions:  barriers and opportunities.  Health Education & Behavior.  42(IS):133S-140S.  Retrieved from:

Hester, J.  (2015). Towards Sustainable Improvemnts in Population Health:  Overview of Community Integration Structures and Emerging Innovations in Financing.  Atlanta, GA:  Centers for Disease Control and Prevention.  Retrieved from:

Phalen, J., Kennedy, A., Hubbard, T., Bear, D., Bowers, P.  (2015).  Reducing Hospital Readmissions Through Medication Management and Improved Patient Adherence.  Indianapolis, IN:  Anthem, Inc.  Retrieved from:

National Academies of Sciences, Engineering, and Medicine.  (2015).  How Modeling Can Inform Strategies to Improve Population Health: Workshop Summary. Washington, DC: The National Academies Press.  Retrieved from:

Betbeze, P.  (2014, Nov. 21).  6 Not-so-good reasons for avoiding population health.  HealthLeaders Media.  Retrieved from:

Carrillo, J.E., Carrillo, V.A., Guimento, R., Mucaria, J., and Leiman, J. (2014, Nov.). The New York-Presbyterian Regional Health Collaborative: a three-year progress report. Health Affairs, 33(11), 1985-1992.

Dhalla, I., and others. (2014, Oct. 1). Effect of a postdischarge virtual ward on readmission or death for high-risk patients: a randomized clinical trial. JAMA, 312(13), 1305-1312.  Retrieved from: 

(2014, October).  A Direct Correlation between HCAHPS Patient Experience of Care Results and Readmissions.  Pensacola, FL:  Studer Group.  Retrieved from:

Betbeze, P.  Strategies for Managing the Post-Acute Environment.  HealthLeaders Media.  Sept. 5, 2014.

Betbeze, P.  Targeting self-insured populations.  HealthLeaders Media.  Aug. 27, 2014.

Gilfillan, R.  Dispersing the population health dividend.  H&HN Daily.  Aug. 27, 2014.

Hoppszallern, S.  Finding the right tools for population health.  H&HN Daily.  Aug. 18, 2014.

Pear, R. Medicare to start paying doctors who coordinate needs of chronically ill patients.  The New York Times.  Aug. 16, 2014.

David, G., and others.  Do patient-centered medical homes reduce emergency department visits?  Health Services Research.  Aug. 12, 2014.

Hong, C., Abrams, M., and Ferris, T.  Toward increased adoption of complex care.  New England Journal of Medicine.  371:491-493, Aug. 7, 2014.

Multistakeholder Input on a National Priority:  Improving Population Health by Working with Communities - Action Guide 1.0.  Washington:  National Quality Forum, Aug. 1, 2014.

Collaborative Healthcare Strategies, Inc.  Hospital Guide to Reducing Medicaid Readmissions.  Rockville, MD:  Agency for Healthcare Research and Quality, Aug. 2014.

Project RED Tool 7: Understanding and Enhancing the Role of Family Caregivers in the Re-Engineered Discharge.  Boston University Medical Center.  Aug. 2014.

Hong, C., Siegel, A., and Ferris, T.  Caring for High-Need, High-Cost Patients:  What Makes for a Successful Care Management Program?   New York: Commonwealth Fund.  Aug. 2014.

Butcher, L.  Physician leaders lower costs through care redesign.  PEJ. Physician Executive.  40(4):14-18, July-Aug. 2014. 

Bikdeli, B. and others.  Place of Residence and Outcomes of Patients With Heart Failure:  Analysis From the Telemonitoring to Improve Heart Failure Outcomes Trail.  Dallas, TX:  American Heart Association, July 29, 2014.

Lee, J.  Preventing readmissions: is there an app for that?  Modern Healthcare.  44(28):18-20, July 14, 2014. 

Fitch, J.C.K.  Advancing a medical home for surgical services.  Modern Healthcare;44(27):25, July 7, 2014. 

Bates, D.W., Saria, S., and others.  Big data in health care: using analytics to identify and manage high-risk and high-cost patients.  Health Affairs.  33(7):1123-1132, July 2014. 

Palmer, L.  Preparing for future patient care delivery models.  MGMA Connection.  14(6):30-33, July 2014. 

McGinnis, T., Crawford, M., and Somers, S.  A State Policy Framework for Integrating Health and Social Services.  New York:  Commonwealth Fund, July 2014.

Commins, J.  Tenet opens population health campus.  HealthLeaders Media.  June 25, 2014.

Jarousse, L.  IT and the ACO.  H&HN.  June 10, 2014.

Bachrach, D., and others.  Addressing Patients' Social Needs.  New York:  Commonwealth Fund, May 2014.

Meltzer, D., and Ruhnke, G.  Redesigning care for patients at increased hospitalization risk:  The comptehensive care physician model.  Health Affairs.  33(5):770-777, May 2014.

Grootveld, K., and others.  Case management in an acute-care hospital:  Collaborating for quality, cost-effective patient care.  Healthcare Quarterly.  17(1):60-65, May 2014.

Herrin, J., and others.  Community factors and hospital readmission.  Health Services Research.  Apr. 9, 2014.

Miller, J., and Gordon, S. The Role of Integrated Service Delivery Models in Addressing the Needs of Adults and Children with Behavioral Health Conditions. National Association of State Mental Health Program Directors, Apr. 2014. 

Goedert, J.  NCQA sets new, higher standards for medical homes. Health Data Management.  Mar. 25, 2014.

A guide for HCAs on safe patient transfers.  Nursing Times.  109(26):1-3, Mar. 7, 2014.

Wilson-Pecci, A.  Care coordination tough to define, measure.  HealthLeaders Media.  Mar. 4, 2014.

Second Curve of Population Health.  Chicago:  American Hopsital Association, Mar. 2014.

Clark, C.  PCMH pilot not associated with cost reductions, study shows.  HealthLeaders Media.  Feb. 27, 2014.

Friedberg, M., and others.  Association between paticipation in a multipayer medical home intervention and changes in quality, utilization, and costs of care.  Journal of the American Medical Association.  311(8):815-825, Feb. 26, 2014.

The doctor's team will see you now.  Wall Street Journal.  Feb. 17, 2014.

Larkin, H.  Population health: The risks & rewards.  H&HN.  Feb. 11, 2014.

Kangovi, S.  The role of community health workers in promoting health:  'Talk to me about anything'.  Human Capital Blog.  Feb. 2014.

Ananth, S.  Coordinating allopathic and CAM care.  H&HN.  Jan. 30, 2014.

Krumholz, H.  Post-hospital syndrome ----  An acquired, transient condition of generalized risk.  New England Journal of Medicine.  368:100-102, Jan. 10, 2014.

Prepublication - Requirements for pursuing behavioral health home certification.  Oakbrook Terrace, IL:  Joint Commission, Jan 1, 2014.

Alper, J.  Population Health Implications of the Affordable Care Act:  Workshop Summary (2014).  Washington:  The National Academies Press, 2014.

Grootveld, K., Wen, V., and others.  Case management in an acute-care hospital: collaborating for quality, cost-effective patient care.  Healthcare Quarterly.  17(1):60-65, 2014.

Institute of Medicine. The Role and Potential of Communities in Population Health Improvement: Workshop Summary.  Washington, DC: National Academies Press, 2014.


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