Scanning the Headlines: Care Management (Archive) 2013-2012

´╗┐Updated on August 15, 2014

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Cantlupe, J.  Can this be the healthiest place in America?  HealthLeaders Media.  Nov. 21, 2013.

Molpus, J.  Anatomy of a readmissions master plan.  HealthLeaders Media.  Nov. 14, 2013.

Fox, M.  What makes U.S. health care so overpriced?  It's not what you think.  NBC News.  Nov. 12, 2013.

Fitzgerald, J., editor.  Strong hospital-SNF relationships reduce readmissions.  HIM-HIPAA Insider.  Nov. 11, 2013.

Nyweide, D.  Concordance between continuity of care reported by patients and measured from administrative data.  Sage Journals.  Oct. 31, 2013. 

Why People Need Coordinated Health Care.  New York:  Commonwealth Fund,  Oct. 31, 2013.

Audet A.  Why people need coordinated care [video]. Commonwealth Fund, Oct. 31, 2013.

Rahman, M., and others.  Effect of hospital-SNF referral linkages on rehospitalization.  Health Services Research.  Oct. 17, 2013.

Mace, S.  Readmissions 'drop like a rock' with predictive modeling.  HealthLeaders Media.  Oct. 8, 2013.

McHugh, M., Berez, J., and Small, D.  Hospitals with higher nurse staffing had lower odds of readmissions penalties than hospitals with lower staffing.  Health Affairs.  32(10):1740-1747, Oct. 2013.

Rosenthal, M., and others.  Effect of a multipayer patient-centered medical home on health care utilization and quality:  The Rhode Island chronic care sustainability initiative pilot program.  Commonwealth Fund, Sept. 10, 2013.

Bradley, E., and others.  Identifying patients at increased risk for unplanned readmission.  Medical Care.  51(9):761-766, Sept. 2013.

Marks, C., Loehrer, S., and McCarthy, D.  Hospital Readmissions:  Measuring for Improvement, Accountability, and Patients.  New York:  Commonwealth Fund, Sept. 2013.

Gold, J.  ACO's coordinated care savings may be contagious.  Kaiser Health News.  Aug. 28, 2013.

Jaffe, M., and others.  Improved blood pressure control associated with a large-scale hypertension program.  Journal of the American Medical Association.  310(7):699-705, Aug. 21, 2013.

Stawicki, E.  Talking scales and telemedicine:  ACO tools to keep patients out of the hospital.  Kaiser Health News.  Aug. 15, 2013.

Anderson, J., editor.  ACOs ask 'activation' experts how to engage passive patients.  AISHealth.  Aug. 7, 2013.

Rodak, S.  CMS responds to 6 major critiques of readmission measure.  Beckers Hospital Review.  Aug. 7, 2013.

Adair, R., and others.  Improving chronic disease care by adding laypersons to the primary care team:  A parallel randomized trial.  Annals of Internal Medicine.  159(3):176-184, Aug. 6, 2013.

Snowbeck, C.  Twin Cities study finds patients fare better with care guides' help.  St. Paul Pioneer Press, Aug. 6, 2013.

Rutherford, N., and others.  How-to Guide:  Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations.  Cambridge, MA:Institute for Healthcare Improvement. Aug. 2, 2013.

Herndon, L., and others.  How-to Guide:  Improving Transitions from the Hospital to Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations.  Cambridge, MA:  Institute for Healthcare Improvement.  Aug. 2, 2013.

Rau, J.  Armed with bigger fines, Medicare to punish 2,225 hospitals for exces readmissions.  Kaiser Health News.  Aug. 2, 2013.

Evdokimoff, S., and others.  How-to Guide:  Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations.  Cambridge, MA:  Institute for Healthcare Improvement, Aug. 2, 2013.

Schall, M., and others.  How-to Guide:  Improving Transitions form the Hospital to the Clinical Office Practice to Reduce Avoidable Rehospitalizations.  Cambridge, MA:  Institute for Healthcare Improvement, Aug. 2, 2013.

Colorado Hospital Association and United Healthcare Initiative Shows Double-Digit Decrease in Readmission Rates, Nearly $3 Million in Health Care Savings in First Year.  Greenwood Village, CO:  Colordo Hospital Association, Aug. 1, 2013.

Casalino, L., and others.  Independent practice associations and physician-hospital organizations can improve care management for smaller practices.  Health Affairs.  32(8):1376-1382, Aug. 2013.

Jackson, C., and others.  Transitional care cut hospital readmissions for North Carolina Medicaid patients with complex chronic conditions.  Health Affairs.  32(8):1407-1415, Aug. 2013

Lyons, J.  HINfographic:  Managing population health.  Township, NJ:  Healthcare Intelligence Network.  July 15, 2013.

Bartolini, E.  Accountable care organizations and innovation:  A changing landscape.  Health Affairs.  June 28, 2013.

Rodak, S.  Why every hospital can't manage population health, and why that's OK.  Becker's Hospital Review.  June 18, 2013.

Punke, H.  5 HIT features most important for ACO, PCMH quality outcomes.  Becker's Hospital Review.  June 17, 2013.

Rau, J.  Panel tells Congress Medicare is unfairly penalizing hospitals serving the poor.  Washington Post.  June 14, 2013.

Cantlupe, J.  Advocate for physician-led ACOs shares secret of sucess.  HealthLeaders Media.  June 13, 2013.

Goodman, D., and others.  Tracking Improvement in the Care of Chronically III Patients:  A Dartmouth Atlas Brief on Medicare Beneficiaries Near the End of Life.  Lebanon, NH:  Dartmouth Institute, June 12, 2013.

Letourneau, R.  Preventing hospital readmissions presents financial paradox.  HealthLeaders Media.  June 10, 2013.

Betbeze, P.  Care coordination needs CEOs.  HealthLeaders Media.  June 7, 2013.

Cantulupe, J.  Primary care finds a (medical) home.  HealthLeaders. 16(5):42, 44-48, June 2013. 

Gamble, M.  ACOs: the least agreed-upon concept in healthcare?  Becker’s Hospital Review.  (6):1, 12-14, June 2013.

Landman, J. H.  A statewide partnership for reducing readmissions.  Healthcare Financial Management.  67(6):78-86, June 2013. 

Role of Small and Rural Hospitals and Care Systems in Effective Population Health Partnership.  June 2013. 

Organizational Assessment - Guide and Tools. RARE Campaign – Reducing Avoidable Readmissions Effectively. Accessed May 31, 2013 at; Also, Participant Resources at

Zaman, A., and Zielinski, L.  Addressing the human factors behind readmissions.  H & HN Hospitals & Health Network.  May 30, 2013.

Clark, C.  Hospitals thinking beyond 30 – day readmissions.  HealthLeaders Media.  May 29, 2013.

Readmission Reductions Program.  Centers for Medicare and Medicaid Services, accessed May 22, 2013.

Vaida, B.  An Alliance for Health Reform Toolkit Produced With Support From the Robert Wood Johnson Foundation.  Washington, DC:  Alliance for Health Reform.  May 21, 2013.

Punke, H.  Managing ESRD patients: one ACO shares its strategy.  Beckers Hospital Review.  May 16, 2013.

Patient-centered medical homes – do they work? Event summary and webcast. Alliance for Health Reform, May 3, 2013.

Hausman, S.  Yes, Virginia, There is a Medical Home.  Kaiser Health News.  May 1, 2013.

Robinson, J. C.  Case studies of orthopedic surgery in California: the virtues of care coordination versus specialization.  Health Affairs.  32(5):921-928, May 2013.

Learning Guide.  Washington:  Beacon Community Program.  May 2013.

Who is Qualified to Coordinate Care?  New York:  Social Work Leadership Institute of the New York Academy of Medicine, May 2013.

Policy Brief: Implementing Care Coordination in the Patient Protection and Affordable Care Act.  New York:  Social Work Leadership Institute of the New York Academy of Medicine, May 2013.

Rabin, R.  Health care's 'dirty little secret':  No one may be coordinating care.  Washington Post.  Apr. 30, 2013.

Collaborative Care:  Hospitals Balance Risk and Revenue with Physicians and Payers.  HealthLeaders Media.  Apr. 30, 2013.

Marshall, T.  Hospital readmissions: how to stop the pain: part 1.  Hospitals & Health Networks.  Apr. 25, 2013.

Selvam, A.  Targeting salt intake – despite controversy.  Modern Healthcare;43(14):18-19, Apr. 8, 2013.

Accountable care case studies., accessed Apr. 2, 2013 at

Elixhauser, A., and Steiner, C.  Readmissions to U.S. Hospitals by Diagnosis, 2010Statistical Brief # 153.  Rockville, MD:  Agency for Healthcare Research and Quality.  Apr. 2013. 

Weiss, A., Elixhauser, A., and Steiner, C.  Readmissions to U.S. Hospitals by Procedure, 2010Statistical Brief # 154.  Rockville, MD:  Agency for Healthcare Research and Quality.  Apr. 2013.

Complex Puzzle:  How Payers Are Managing Complex and Chronic Care.  California Healthcare Foundation.  Apr. 2013.

New chart:  How healthcare identifies individuals for care transition management.  Healthcare Performance Benchmarks.  Apr. 2013.

Carlson, J.  Behind the scenes although patients may not know it, ACOs are increasingly on their team, aiming to provide better care at lower costs.  ModernHealthcare.  Mar. 29, 2013.,d.aWc

CMS unveils chronic conditions dashboard. AHA News Now, Mar. 28, 2013.  

A Path Forward on Medicare Readmissions.  New England Journal of Medicine, Mar. 28, 2013.

Donze, J.  Potentially avoidable 30-day hospital readmissions in medical patients.  Journal of American Medical Association (JAMA).  1-7, Mar. 25, 2013.

Faber, M., and others.  Survey of 5 european countries suggests that more elements of patient centered medical homes could improve primary care.  Health Affairs.  Mar.  19, 2013.

CMS Revises Hospital Readmission Policies For The Second Time.  Becker’s Hospital Review, Mar. 15, 2013.

Health IT in long-term and post acute care.  Issue Brief.  Mar. 15, 2013.

Lavizzo-Mourey, R.  The human face of hospital readmissions.  Health Affairs.  Mar. 14, 2013.

Refining the Hospital Readmissions Reduction Program.  Medicare Payment Advisory System, Mar. 7, 2013.

STAAR Issue Brief: The Effect of Medicare Readmissions Penalties on Hospitals’ Efforts to Reduce Readmissions.  Institute for Healthcare Improvement, Mar. 6, 2013. 

Torio, C., Elixhauser, A., and Andrews, R.  Trends in potentially preventable hospital admissions among adults and children, 2005-2010Statistical Brief # 151.  Rockville, MD:  Agency for Healthcare Research and Quality, Mar. 2013.

Lewis, V., and others.  Attributing patients to accountable care organizations: performance year approach aligns stakeholder’s interests.  Health Affairs. 32 (3): 587-595, Mar. 2013.

Verret, D., and Rohloff, R. M.  The value of palliative care.  hfm.  67(3):50-54, Mar. 2013. 

Williams, J.  A new model for care: population management.  hfm.  67(3):68-76, Mar. 2013. 

Jack, B., and others.  Re-Engineered Discharge (RED) Toolkit. Rockville, MD: Agency for Healthcare Research and Quality; Mar. 2013.

Recent Medicare Initiatives to Improve Care Coordination and Transitional Care for Chronic Conditions.  AARP Public Policy Institute, Mar. 2013.

Clark, C.  Dartmouth readmissions report shows scant progress.  HealthLeaders Media.  Feb. 12, 2013.

Cooper, L, and others. Comparative Effectiveness of Standard versus Patient-Centered Collaborative Care Interventions for Depression among African Americans in Primary Care Settings: The BRIDGE Study.   Health Services Research.  48(1):150-174, Feb. 2013.

Garcia, A., Pomykala, A., and Siegel, S.  U.S. health care is moving upstream.  Health Progress;94(1):7-13, Jan.-Feb. 2013.

Evashwick, C.  Public health for private health care.  Health Progress;94(1):15-19, Jan.-Feb. 2013.

Pestronk, R.M., Elligers, J.J., and Laymon, B.  Collaborating for healthy communities.  Health Progress;94(1):21-25, Jan.-Feb. 2013.

Crawford, M.  Catholic health systems steer the new course.  Health Progress;94(1):27-30, Jan.-Feb. 2013.

Lysaught, M.T.  Reverse innovation from the least of our neighbors.  Health Progress;94(1):45-52, Jan.-Feb. 2013.

Population health means doing business differently.  Health Progress;94(1):72-75, Jan./Feb. 2013.

Squazzo, J. D.  Palliative care: impact on quality and cost.  Healthcare Executive.  28(1):26-28, 30, 32, 34, 36, 38, Jan./Feb. 2013. 

Considine, W. H.  Pediatric palliative care.  Healthcare Executive.  28(1):68, 70-71, Jan./Feb. 2013.

Berry, J., and others.  Pediatric readmission prevalence and variability across hospitals. Journal of American Medical Association (JAMA).  309(4):372-380, Jan. 23/30, 2013.

Brock, J., and others.  Association between quality improvement for care transitions in communitie and rehospitalizations among Medicare beneficiaries.  Journal of American Medical Association (JAMA).  309(4):381-391, Jan. 23/30, 2013.

Brenner, J. C.  Jeffrey C. Brenner: on driving down the cost of care.  Healthcare Financial Management.  67(1):72-75, Jan. 2013.

For Health Care ProvidersCare Coordination.  New York:  United Hospital Fund, 2013. 

For Family Caregivers.  A Family Caregiver's Guide to Care Coordination.  New York:  United Hospital Fund, 2013.

Bader, B.  Advent of “Care Systems” Means Governance Must Also Transform.  Chicago, IL:  American Hospital Association.  2013.

Medicare Discloses Hospitals’ Bonuses, Penalties Based on Quality.  Kaiser Health News, Dec. 20, 2012.

Butcher, L.  Admission plan eases patient transition and care coordination.  Healthcare Financial Managment.  Dec. 14, 2012.

Kind, A. J., and others.  Low-cost transitional care with nurse managers making mostly phone contact with patients cut re-hospitalization at a VA hospital.  Health Affairs.  31(12):2659-2668, Dec. 2012.

Albert, B.  Navigating care management.  HFM;66(12):62-66, Dec. 2012.

Martsolf, G., and others.  The Patient-Centered Medical Home and Patient ExperienceHealth Services Research.  47(6):2273-2295, Dec. 2012.

Krieger, N.  Who and what is a “population”?  Historical debates, current controversies, and implications for understanding “population health” and rectifying health inequities.  The Milbank Quarterly;90(4):634-681, Dec. 2012.

McCarthy, D.  University of California, San Francisco Medical Center:  Reducing Readmissions Through Heart Failure Care Management.  New York:  Commonwealth Fund, Nov. 14, 2012.

Supporting Health Child Development Through Medical Hones: Strategies from ABCD III States.  Washington, DC:  National Academy for State Health Policy.  Nov. 2012.

Clark, C.  A trigger for hospital readmissions ID'd by geriatric experts.  HealthLeaders Media.  Oct.15, 2012.

Rau, J. Medicare revises hospitals' readmissions penalties.  KHN Kaiser Health News.  Oct. 3, 2012.

Whitney, E.  Hospitals need networks to prevent readmissions.  KHN Kaiser Health News.  Oct. 3, 2012.

Elliott, V.  Insurers latest to champion medical homes.  American Medical News. Oct. 1, 2012.

Population Health Management in Physician Practice: a Call to Action.  Washington, DC:  Care Continuum Alliance.  Oct. 2012.

Hesselink, G., and others.  Improving patient handovers from hospital to primary care : a systematic review.  Annals of Internal Medicine; 157 (6) 417-428, Sept. 18,2012.

Rau, J.  Hospital readmission rates dropping slightly, new study finds.  Capsules Kaiser Health News.  Sept. 14,2012.

Improving care transitions.  Better coordination of patient transfers among care sites and the community could save money and improve the quality care.  Health Affairs. Sept. 13, 2012.

Alphabet soup of care delivery transformation.  Alliance for Health Reform.  Sept. 10, 2012.

Spector, W., and others.  Transitions Between Nursing Homes and Hospital in the Elderly Population, 2009.  Rockville, MD:  Agency for Healthcare Research and Quality.  Sept. 2012.

Evidence Report/Technology Assessment Number 208 Medication Adherence Interventions: Comparative Effectiveness.  Rockville, MD:  Agency for Healthcare Research and Quality. Sept. 2012.

Qasim, M., and Andrews, R.  Post surgical readmissions among patients living in the poorest communities 2009.  Healthcare Cost and Utilization Project. Sept. 2012.

Publisher is Medicare Payment Advisory Commission [MedPAC].

Elliott, V.  Revised CPT book includes new codes for care coordination.  Aug. 16, 2012.

McGinnis, T.  Advancing Accountable Care Organizations in Medicaid.  New York:  Commonwealth Fund, Aug. 15, 2012.

Rau, J.  Medicare to penalize 2,211 hospitals for excess redmissions.  Kaiser Health News.  Aug. 13, 2012.

Tabbush, V.  Overview of preparing community-based organizations for successful health care partnerships.  Long Beach, CA:  Scan Foundation.  Aug. 2012.

Advanced Illness Management Stategies.  Chicago:  American Hospital Association, Aug. 2012.

Oh, J.  AF4Q hospitals improve readmissions, language services and other quality measures.  Becker's Hospital Review.  July 31, 2012.

Rodak, S.  51 hospitals with the lowest 30-day readmission rates from heart failure.  Beckers' Hospital Review.  July 26, 2012.

Spoerl, B.  9 recently formed commercial ACOs.  Becker's Hospital Review.  July 23, 2012.

Rau, J.  Medicare IDs few hospitals as outliers in readmissions.  Kaiser Health News.  July 23, 2012.

Rau, J.  Hsopitals' readmissions rates not budging.  Washington Post.  July 19, 2012.

Breakthroughs.  HealthLeaders Media.  July 9, 2012.

Mullin, E.  UPMC medical home slashes readmissions, cuts utilization costs.  Dorland Health.  July 6, 2012.

Patient-Centered Medical Home Closing the Quality Gap: Revisiting the State of the Science Executive Summary.  Rockville, MD:  Agency for Healthcare Research and Quality. Number 208. July 03, 2012.

O'Malley, A., and others.  After-Hours and Its Coordination with Primary Care in the U.S.  New York:  Commonwealth Fund, July 2, 2012.

Murugan, V., Drozd, E., and Dietz, K.  Analysis of Care Coordination Outcomes a Comparison of the Mercy Care Plan Population.  Washington, DC:  Avalere. July, 2012.

CMS requires more discharge planning under Medicare conditions of participation (with:  Improving the patient discharge planning process).  AISHealth, June 10, 2013.

Cantlupe, J.  How coordinated care can ground frequent fliers.  HealthLeaders Media. June 7, 2012.

Medicare and the health care delivery system: report to Congress [includes chapters on care coordination]. Medicare Payment Advisory Commission, June 2012.

Schall, M., and others.  How-to Guide:  Improving Transitions from the Hospital to the Clinical Office Practice to Reduce Avoidable Rehospitalizations.  Cambridge, MA:  Insitutute for Healthcare Improvement, June 2012.

Rutherford, P., and others.  How-to Guide:  Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations.  Cambridge, MA:  Insitutute for Healthcare Improvement, June 2012.

Herndon, L., and others.  How-to Guide:  Improving Transitions from the Hospital to Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations.  Cambridge, MA:  Insitutute for Healthcare Improvement, June 2012.

Evdokimoff, S., and others.  How-to-Guide:  Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations.  Cambridge, MA:  Insitutute for Healthcare Improvement, June 2012.

Johnson, T., and others.  Hospital care may not affect the risk of readmission.  Quality Management in Health Care.  21(2):68-73, Apr./June 2012.

Commins, J.  Minnesota 'health care homes' model shows promise.  HealthLeaders Media.  May 30, 2012.

Medical Homes 101.  Washington, DC:  Grant Makers Health.  May 21, 2012.

Ku, L., and others.  Coordinating and integrating care for safety net patients:  Lessons from six communities.  Washington:  George Washington University.  May 21, 2012.

Berenson, J., and others.  Achieving Better Quality of Care for Low-Income Populations:  The Roles of Health Insurance and the Medical Home in Reducig Health Inequities.  New York:  The Commonwealth Fund, May 16, 2012.

Florida Blue launches oncology ACO.  HealthLeaders Media, May 14, 2012. 

Taylor, M.  Hospital engagement networks:  10 big goals in 2 short years.  H&HN.  May 5, 2012.

Emerging Medicaid Accountable Care Organizations: The Role of Managed Care.  Washington, DC:  Henry J. Kaiser Family Foundation.  May, 2012. 

Chapter 6: Care Coordination. IN: National Healthcare Quality Report, 2011. Agency for Healthcare Research and Quality, Apr. 2012.

Birk, S.  Reducing hospital readmissions.  Healthcare Executive;27(2):17-20, 22, 24, Mar.-Apr. 2012.

Clark, C.  30-day readmissions rule under two-pronged attack.  HealthLeaders Media.  Mar. 29, 2012.

Clark, C.  10 things we don't know about looming readmission penalties.  HealthLeaders Media.  Mar. 29, 2012.

Lumpkin, J., and others.  Expanding "hot spotting" to new communities; a policy briefing on what RWJF is learning about coordinating health care for high-utilizers.  Robert Wood Johnson Foundation, Mar. 29, 2012.

Joynt, K., and Jha, A. Thirty-day readmissions ---- truth and consequences.  New England Journal of Medicine.  Mar. 28, 2012.

Berenson, R., Paulus, R., and Kalman, N.  Medicare's readmssions-reduction program ---- a positive alternative.  Mar. 28, 2012.

Yeh, R., and others. Sources of Hospital Variation in Short-Term Readmission Rates After Percutaneous Coronary Intervention. Circulation: Cardiovascular Interventions. 5:227-236, online pre-print release, Mar. 20, 2012.

Rosenthal, M., and others.  Recommended Core Measures for Evaluating the Patient-Centered Medical Home:  Cost, Utilization, and Clinical Quality.  New York:  Commonwealth Fund, May 16, 2012.

Clark, C.  Readmission more likely for non-surgical.  HealthLeaders Media.  Mar. 9, 2012.

Patient Centered Medical Homes: a New Era in Primary Care.  Washington, DC:  National Business Coalition on Health.  March, 2012.

Hines, P., and Maglio, B.  Reducing hospital readmissions.  H&HN.  Feb. 2, 2012.

30-day Readmissions following Hospitalizations for Chronic vs. Acute Conditions, 2008. Agency for Healthcare Research and Quality, HCUP Statistical Brief #127, Feb. 2012.

Thygeson, N., and others.  Using Fuzzy Set Qualitative Comparative Analysis (fs/QCA) to Explore the Relationship between Medical “Homeness” and QualityHealth Services Research.  47(1 pt1):22-45, Feb. 2012.

Hollingsworth, J., and others.  Physician Practices and Readiness for Medical Home Reforms: Policy, Pitfalls, and PossibilitiesHealth Services Research.  47(1pt2), Feb. 2012.

Gray, M.,Weng, W., and Holmboe, E.   An Assessment of Patient-Based and Practice Infrastructure–Based Measures of the Patient-Centered Medical Home: Do We Need to Ask the Patient?  Health Services Research.  47(1 pt.1):4-21, Feb. 2012.

Early Evidence on the Patient-Centered Medical Home.  Rockville, MD:  Agency for Healthcare and Quality, Feb. 2012. on the PCMH 2 28 12.pdf

Podulka, J., and others. 30-day readmissions following hospitalizations for chronic vs. acute conditions, 2008.  Rockville, MD:  Agency for Healthcare Research and Quality, Feb. 2012.

Lourde, K.  Physicians moving in.  Provider.  38(2):22-23, 25-26, 28, 30, 32-33, Feb. 2012. 

Coordination strategy for post acute care and long term care performance measurement.  National Quality Forum.  Feb. 2012.

Lindeman, S., and Lyke, J.P.  Smooth transitions reduce hospital visits.  Provider.  38(2):35-36, 38, Feb. 2012.

Tocknell, M.  CBO report on Medicare demos draws mixed response.  HealthLeaders Media.  Jan. 23, 2012.

Nelson, L.  Lessons From Medicare's Demonstration Projects on Disease Management, Care Coordination, and Value-Based Payment.  Washington:  Congressional Budget Office, Jan. 18, 2012.

Coordinating Care for Adults With Complex Care Needs in the Patient-Centered Medical Home:  Challenges and Solutions.  Rockville, MD:  Agency for Healthcare Research and Quality, Jan. 2012. Care for Adults with Complex Care Needs.pdf

American Hospital Association.  Bringing Behavioral Health into the Care Continuum: Opportunities to Improve Quality, Costs and Outcomes.  Trendwatch, Jan. 2012.

Achieving Team-Based Health Care Delivery.  Chicago:  American Hospital Association, 2012.

Nielsen, M., and others.  Benefits of Implementing the Primary Care Patient Centered Medical Home.  Washington, DC:  Patient Centered Primary Care Collaborative. 2012.

Griffin, R., Harden, F., and Nolan, C.  Using Care Bundles to Improve Health Care Quality.  Cambridge, MA:  Institute for Healthcare Improvement, 2012.

Dhalla, I., and others.  Toward safer transitions:  How can we reduce post-discharge adverse events?  Healthcare Quarterly.  15(Special issue):63-67, 2012.

Living Well with Chronic Illness:  A Call for Public Health Action.  Washington:  The National Academies Press, 2012.

Implementation and Evaluation: A Population Health Guide for Primary Care Models.  Washington, DC:  Care Continuum Alliance.  2012.

Managing Obesity to Improve Population Health: a Toolkit.  Washington, DC:  Care Continuum Alliance.  2012.

Participant Engagement and the Use of Incentives Considerations.  Washington, DC:  Care Continuum Alliance.  2012.


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