Altarum Institute. Medicaring.org. [Web site]. http://medicaring.org/Updated 2013. Accessed July 30, 2014. Medicaring is the exciting idea that Americans can learn to build reliable, effective, and efficient arrangements for services to support one another when we must live with serious chronic conditions, mostly associated with older age or the last years of life — and that such a care system will be substantially different from what we have now. We are working on policy, economics, professional development, public education, community demonstrations and a dozen other fronts to learn what works and to forge the commitment to change.

August 7, 2019

Medicaring.org

Altarum Institute. Medicaring.org. [Web site]. http://medicaring.org/Updated 2013. Accessed July 30, 2014. Medicaring is the exciting idea that Americans can learn to build reliable, effective, and efficient arrangements for services to support one another when we must live with serious chronic conditions, mostly associated with older age or the last years […]
Read More
Altarum Institute. Medicaring.org. [Web site]. http://medicaring.org/Updated 2013. Accessed July 30, 2014. Medicaring is the exciting idea that Americans can learn to build reliable, effective, and efficient arrangements for services to support one another when we must live with serious chronic conditions, mostly associated with older age or the last years of life — and that such a care system will be substantially different from what we have now. We are working on policy, economics, professional development, public education, community demonstrations and a dozen other fronts to learn what works and to forge the commitment to change.
Read Less
Palliative Care, End-of-Life

August 7, 2019

CMAG Case Management Adherence Guidelines. Version 2.0

Case Management Society of America. Case Management Adherence Guidelines. Version 2.0.http://www.cmsa.org/portals/0/pdf/CMAG2.pdf.Published June 2006. Accessed 7/9/14. Guidelines form the case Management Society of America for improving patient adherence to medication therapies
Case Management Society of America. Case Management Adherence Guidelines. Version 2.0.http://www.cmsa.org/portals/0/pdf/CMAG2.pdf.Published June 2006. Accessed 7/9/14. Guidelines form the case Management Society of America for improving patient adherence to medication therapies
Read Less
http://www.cmsa.org/portals/0/pdf/CMAG2.pdf

August 7, 2019

The Promise of Care Coordination: Models that Decrease Hospitalizations and Improve Outcomes for Medicare Beneficiaries with Chronic Illnesses

Brown R. The National Coalition On Care Coordination.The Promise of Care Coordination: Models that Decrease Hospitalizations and Improve Outcomes for Medicare Beneficiaries with Chronic Illnesses. http://www.nyam.org/social-work-leadership-institute/docs/N3C-Promise-of-Care-Coordination.pdf. March 2009. Accessed April 26, 2013. A synthesis of the literature on best practices in care management and transitions of care models as well […]
Read More
Brown R. The National Coalition On Care Coordination.The Promise of Care Coordination: Models that Decrease Hospitalizations and Improve Outcomes for Medicare Beneficiaries with Chronic Illnesses. http://www.nyam.org/social-work-leadership-institute/docs/N3C-Promise-of-Care-Coordination.pdf. March 2009. Accessed April 26, 2013. A synthesis of the literature on best practices in care management and transitions of care models as well as outcomes.
Read Less
http://www.nyam.org/social-work-leadership-institute/docs/N3C-Promise-of-Care-Coordination.pdf

August 6, 2019

Defining and disseminating the hospital-at-home model

Leff B. Defining and disseminating the hospital-at-home model. CMAJ.2009;180(2):156-157.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2621275/. Accessed 7/9/14.The hospital, which is the “gold standard” for the delivery of acute medical care, is not an ideal care environment for many patients.1 Iatrogenic events such as nosocomial infections, pressure sores, falls and delirium are common.2 New functional impairment commonly […]
Read More
Leff B. Defining and disseminating the hospital-at-home model. CMAJ.2009;180(2):156-157.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2621275/. Accessed 7/9/14.The hospital, which is the "gold standard" for the delivery of acute medical care, is not an ideal care environment for many patients.1 Iatrogenic events such as nosocomial infections, pressure sores, falls and delirium are common.2 New functional impairment commonly occurs during hospital stay. Suboptimal transitions in care at the time of hospital discharge also occur, contributing, ironically, to readmission to hospital.3 Furthermore, hospital care is very expensive. In this issue, Shepperd and colleagues4 present a meta-analysis of the effectiveness of "hospital-at-home programs."
Read Less
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2621275/

August 6, 2019

Variations in Service Use in the Program of All-Inclusive Care for the Elderly (PACE): Is More Better?

Temkin-Greener H, Bajorska A, Mukamel DB. Gerontol A Biol Sci Med Sci.2008;63(7): 731-738. http://biomedgerontology.oxfordjournals.org/content/63/7/731.abstract?sid=565d77dd-7d89-4ba5-a8b6-7df5bc49e08a. Accessed July 24, 2014. Background: To date, there has been little empirical evidence about the relationship between service use and risk-adjusted functional outcomes among the frail, chronically ill elderly population. The Program of All-Inclusive Care for the […]
Read More
Temkin-Greener H, Bajorska A, Mukamel DB. Gerontol A Biol Sci Med Sci.2008;63(7): 731-738. http://biomedgerontology.oxfordjournals.org/content/63/7/731.abstract?sid=565d77dd-7d89-4ba5-a8b6-7df5bc49e08a. Accessed July 24, 2014. Background: To date, there has been little empirical evidence about the relationship between service use and risk-adjusted functional outcomes among the frail, chronically ill elderly population. The Program of All-Inclusive Care for the Elderly (PACE) offers a unique model within which to investigate this relationship. We examine variation in the risk-adjusted utilization of acute, rehabilitative, and supportive services in PACE, and assess whether use of these services is associated with risk-adjusted functional outcomes.
Read Less
http://biomedgerontology.oxfordjournals.org/content/63/7/731.abstract?sid=565d77dd-7d89-4ba5-a8b6-7df5bc49e08a

August 6, 2019

National Transitions of Care Coalition

National Transitions of Care Coalition (NTOCC). [Web site]. Http://www.ntocc.org/Home.aspx . Updated 2014. Accessed July 29, 2014. The National Transitions of Care Coalition is a 501©(4) organization dedicated to addressing a serious U.S. health care issue: filling the gaps that occur when patients leave one care setting and move to another […]
Read More
National Transitions of Care Coalition (NTOCC). [Web site]. Http://www.ntocc.org/Home.aspx . Updated 2014. Accessed July 29, 2014. The National Transitions of Care Coalition is a 501©(4) organization dedicated to addressing a serious U.S. health care issue: filling the gaps that occur when patients leave one care setting and move to another care setting. These transitions include patients moving from primary care to specialty physicians; moving or transferring patients from the emergency department to intensive care or surgery; and when patients are discharged from the hospital to home, assisted living arrangements, or skilled nursing facilities. The U.S. health care system often fails to meet the needs of patients during these transitions because care is rushed and responsibility is fragmented, with little communication across care settings and multiple providers. Since 2006, NTOCC’s Advisors Council of over 30 organizations has shared a common goal of improving the quality of Transitions of Care. Working in conjunction with 450 Associate Member organizations and over 3,000 individual professional subscribers, NTOCC has developed tools and resources made available to everyone in the health care industry including providers, payers, patients and consumers. NTOCC’s mission is supported by the Partners Council made up of innovative companies leading critical change in health care coordination.
Read Less
Http://www.ntocc.org/Home.aspx

August 6, 2019

Post-Hospital Care Transitions: Patterns, Complications, and Risk Identification

Coleman EA, Min SJ, Chomiak A, et al. Post-Hospital Care Transitions: Patterns, Complications, and Risk Identification. Health Serv Res. 2004;39(5):1423-1440. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361078/ . Accessed August 7, 2014. Principle Findings: 46 distinct types of care patterns were observed during the 30 days following hospital discharge. Among these patterns, 444 episodes (61.2 percent) […]
Read More
Coleman EA, Min SJ, Chomiak A, et al. Post-Hospital Care Transitions: Patterns, Complications, and Risk Identification. Health Serv Res. 2004;39(5):1423-1440. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361078/ . Accessed August 7, 2014. Principle Findings: 46 distinct types of care patterns were observed during the 30 days following hospital discharge. Among these patterns, 444 episodes (61.2 percent) were limited to a single transfer, 130 episodes (17.9 percent) included two transfers, 62 episodes (8.5 percent) involved three transfers, and 31 episodes (4.3 percent) involved four or more transfers. 59 episodes (8.1 percent) resulted in death. Between 13.4 percent and 25.0 percent of post-hospital care patterns in the 1998 sample were classified as complicated. The area under the receiver operating curve was 0.771 for a predictive index that utilized administrative data and 0.833 for an index that used a combination of administrative and self-reported data. Conclusions: Post-hospital care transitions are common among Medicare beneficiaries and patterns of care vary greatly. A significant number of beneficiaries experienced complicated care transitions – a finding that has important implications for both patient safety and cost containment efforts. Patients at-risk for complicated care patterns can be identified using data available at the time of hospital discharge.
Read Less
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361078/

August 6, 2019

Effects of Care Coordination on Hospitalization, Quality of Care, and Health Care Expenditures Among Medicare Beneficiaries: 15 Randomized Trials

Peikes D, Chen A, Schore J, Brown R. Effects of Care Coordination on Hospitalization, Quality of Care, and Health Care Expenditures Among Medicare Beneficiaries. JAMA. 2009;301(6). Http://jama.jamanetwork.com/article.aspx?articleid=183370 Accessed 7/9/14. Medicare expenditures of patients with chronic illnesses might be reduced through improvements in care, patient adherence, and communication.
Peikes D, Chen A, Schore J, Brown R. Effects of Care Coordination on Hospitalization, Quality of Care, and Health Care Expenditures Among Medicare Beneficiaries. JAMA. 2009;301(6). Http://jama.jamanetwork.com/article.aspx?articleid=183370 Accessed 7/9/14. Medicare expenditures of patients with chronic illnesses might be reduced through improvements in care, patient adherence, and communication.
Read Less
http://jama.jamanetwork.com/article.aspx?articleid=183370