Scanning the Headlines: Care Management

Mongeon, M., Levi, J., and Heinrich, J.  (2017, Nov. 6).  Elements of Accountable Communities for Health:  A Review of the Literature.  Washington:  National Academy of Medicine.  Retrieved from:  https://nam.edu/elements-of-accountable-communities-for-health-a-review-of-the-literature/

Kruse, A., Gibbs, S., and Smith, L.  (2017, Nov.).  Advancing Medicare and Medicaid Integration:  Key Program Features and Factors Driving State Investment.  Hamilton, NJ:  CHCS Center for Health Care Strategies, Inc.  Retrieved from:  https://www.chcs.org/media/INSIDE-Attributes-Brief_112917.pdf

Thomas-Henkel, C., and Schulman, M.  (2017, Oct.).  Screening for Social Determinants of Health in Populations with Complex Needs:  Implementation Considerations.  Princeton, NJ:  Robert Wood Johnson Foundation.  Retrieved from:  https://www.chcs.org/resource/screening-social-determinants-health-populations-complex-needs-implementation-considerations/

Krumholz, H., and others.  (2017, Sept. 14).  Hospital-readmission risk - isolating hospital effects from patient effects.  New England Journal of Medicine.  377:1055-1064.  Retrieved from:  http://www.nejm.org/doi/10.1056/NEJMsa1702321

(2017, Sept.).  Designing a High-Performing Health Care System for Patients with Complex Needs: Ten Recommendations for Policymakers, Expanded and Revised Edition.  New York:  The Commonwealth Fund and the London School of Economics and Political Science.  Retrieved from:  http://www.commonwealthfund.org/~/media/files/publications/fund-report/2017/aug/roland_10_recommendations_for_complex_patients_revisedexpanded.pdf

Milstein, MD, A.  (2017, July 27).  Targeting, tailoring, and trimming chronic illness care.  New England Journal of Medicine Catalyst.  Retrieved from:  http://catalyst.nejm.org/videos/tailoring-chronic-illness-care/

Jones, K., and Weedon, D.  (2017, July 19).  From co-located to integrated teams:  How Utah's neurobehavior HOME program changed its culture.  New England Journal of Medicine Catalyst.  Retrieved from:  http://catalyst.nejm.org/integrated-teams-utah-home-program/

Geva, A., and others.  (2017, July 8).  Provider Connectedness to Other Providers Reduces Risk of Readmission After Hospitalization for Heart Failure.  Thousand Oaks, CA:  Sage Publishers.  Retrieved from:  http://journals.sagepub.com/doi/abs/10.1177/1077558717718626

Matheson, S., and others.  (2017, June).  Optimizing the Value of Skilled Nursing Facilities (SNFs) in Value-Based Care.  Chicago:  Leavitt Partners.  Retrieved from: https://leavittpartners.com/2017/06/optimizing-value-skilled-nursing-facilities-snfs-value-based-care/

Long, P., and others.  (2017, June).  Effective Care for High-Need Patients.  Washington:  National Academy of Medicine.  Retrieved from:  https://nam.edu/wp-content/uploads/2017/06/Effective-Care-for-High-Need-Patients.pdf

Thompson, M., and others.  (2017, May).  Most hospitals received annual penalties for excess readmissions, but some fared better than others.  Health Affairs.  36(5):893-901.  Retrieved from:  http://content.healthaffairs.org/content/36/5/893.abstract

Wilson, A.  (2017, Apr. 20).  Adding this step to discharge planning slashes hospital readmissions by 25%.  HealthLeaders Media.  Retrieved from:  http://www.healthleadersmedia.com/quality/adding-step-discharge-planning-slashes-hospital-readmissions-25

Penm, J., and others.  (2017, Mar./Apr.).  Minding the gap:  Factors associated with primary care coordination of adults in 11 countries.  The Annals of Family Medicine.  15(2):113-119.  Retrieved from: http://www.annfammed.org/content/15/2/113.full

Sinaiko, A., Meyers, D., and Rosenthal, M.  (2017, Mar. 28).  To The Point:  Review of Medical Homes Shows Reduction in Spending for High-Risk Patients, But Design and Implementation Matter.  New York City:  The Commonwealth Fund.  Retrieved from:  http://www.commonwealthfund.org/publications/blog/2017/mar/review-of-medical-homes

Hostetter, M., and Klein, S., and McCarthy, D.  (2017, Mar. 28).  CareMore: Improving Outcomes and Controlling Health Care Spending for High-Needs Patients.  New York City:  The Commonwealth Fund.  Retrieved from: http://www.commonwealthfund.org/publications/case-studies/2017/mar/caremore

Driessen, Ph.D., J., and Zhang, Ph.D., Y.  (2017, Mar. 1).  Trends in the inclusion of mental health providers in Medicare shared savings program ACOs.  Psychiatric Services. 68(3):303-305.  Retrieved from:  http://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201600119

Sinaiko, A., and others.  (2017, Mar.).  Synthesis of research on patient-centered medical homes brings systematic differences into relief.  Health Affairs.  36(3):500-508.  Retrieved from:  http://content.healthaffairs.org/content/36/3/500.abstract

Tobin, E., and others.  (2017, Mar.).  Behavioral Health Integration in Pediatric Primary Care.  New York:  Milbank Memorial Fund.  Retrieved from:  https://www.milbank.org/wp-content/uploads/2017/03/MMF_BHI_REPORT_FINAL.pdf

Afendulis, C., and others.  (2017, Mar.).  Early impact of carefirst's patient-centered medical home with strong financial incentives.  Health Affairs.  36(3):468-475.  Retrieved from:  http://content.healthaffairs.org/content/36/3/468.abstract

Shah, R.  (2017, Mar.).  Starting small with population health management.  Healthcare Financial Management Association.  Retrieved from: http://www.hfma.org/Content.aspx?id=52922

Sinaiko, A. and others.  (2017, Mar.).  Synthesis of research on patient-centered medical homes brings systematic differences into relief.  Health Affairs.  36(3):500-508.  Retrieved from:  http://content.healthaffairs.org/content/36/3/500.abstract

(2017, Feb. 21).  Care Redesign Guide: Better Health and Lower Costs for Patients with Complex Needs.  Cambridge, MA:  Institute for Healthcare Improvement.  Retrieved from:  http://www.careredesignguide.org

McWilliams, J., and others.  (2017, Feb. 13).  Changes in Postacute Care in the Medicare Shared Savings Program.  Chicago:  American Medical Association.  Retrieved from:  http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2601418

McConnell, K., and others.  (2017, Feb. 13).  Early Performance in Medicaid Accountable Care Organizations.  A Comparison of Oregon and Colorado.  Chicago:  American Medical Association.  Retrieved from: http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2601417

Colla, C., and Fisher, E.  (2017, Feb. 13).  Moving Forward with Accountable Care Organizations.  Chicago:  American Medical Association.  Retrieved from:  http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2601414

Toyin, I.  (2017, Jan. 25).  Weaving whole-person health throughout an accountable care framework:  The social ACO.  Health Affairs Blog.  Retrieved from:  http://healthaffairs.org/blog/2017/01/25/weaving-whole-person-health-throughout-an-accountable-care-framework-the-social-aco/

Sederstrom, J.  (2017, Jan. 23).  ACOS:  Improving care through nonmedical services.  Managed Care.  Retrieved from: http://www.managedhealthcareconnect.com/article/acos-improving-care-through-nonmedical-services

Powers, B., Donoff, B., and Jain, S.  (2017, Jan. 19). Bridging the dental divide:  Overcoming barriers to integrating oral health and primary care.  Health Affairs Blog.  Retrieved from: http://healthaffairs.org/blog/2017/01/19/bridging-the-dental-divide-overcoming-barriers-to-integrating-oral-health-and-primary-care/

Bhattacharya, D., and Bhatt, J.  (2017).  Seven foundational principles of population health policy.  Population Health Management.  Retrieved from: http://online.liebertpub.com/doi/pdfplus/10.1089/pop.2016.0148

(2017).  Integrating the Patient and Caregiver Voice into Serious Illness Care:  Proceedings of a Workshop (2017).  Chapter: Front Matter.  Washington:  The National Academies of Sciences, Engineering, and Medicine.  Retrieved from:  https://www.nap.edu/catalog/24802/integrating-the-patient-and-caregiver-voice-into-serious-illness-care

(2017).  Improving Care for High-Need, High-Cost Patients.  Chicago:  American Hospital Association.  Retrieved from:  http://www.hpoe.org/Reports-HPOE/2017/improving-care-for-high-need-high-cost-patients.pdf

Long, P., and others, editors.  (2017).  Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health.  Washington, DC: National Academy of Medicine.   Retrieved from:  https://nam.edu/effective-care-for-high-need-patients/

Mileski, M., and others. (2017). An investigation of quality improvement initiatives in decreasing the rate of avoidable 30-day, skilled nursing facility-to-hospital readmissions: A systematic review. Clinical Interventions in Aging, 12, 213-222.Retrieved from:  https://www.dovepress.com/getfile.php?fileID=34598.

Compton-Phillips, A., and Mohta, N.  (2016, Nov. 10).  Care redesign survey:  Strengthening the post-acute care connection.  NEJM Catalyst.  Retrieved from: http://catalyst.nejm.org/strengthening-post-acute-care-connection

Conway, P. (2016, Sept. 13).  New data:  49 states plus DC reduce avoidable hospital readmissions.  CMS Blog.  Retrieved from: https://blog.cms.gov/2016/09/13/new-data-49-states-plus-dc-reduce-avoidable-hospital-readmissions/ 

Boccuti, C., and Casillas, G.  (2016, Sept.).  Aiming for Fewer Hospital U-Turns:  The Medicare Hospital Readmission Reduction Program.  Menlo Park, CA:  Henry J. Kaiser Family Foundation.  Retrieved from:  http://files.kff.org/attachment/Issue-Brief-Fewer-Hospital-U-turns-The-Medicare-Hospital-Readmission-Reduction-Program

Chase, J.  (2016, July 22).  "Communicating Wisely":  Design, Implementation and Outcomes of an Email-Based Care Transitions Bundle.  San Diego, CA:  Society of Hospital Medicine.  Retrieved from:  http://www.shmabstracts.com/abstract/communicating-wisely-design-implementation-and-outcomes-of-an-email-based-care-transitions-bundle/

Pearl, R., and Loftus, B.  (2016, June 22).  How multi-specialty hubs fills a major gap in the care continuum.  New England Journal of Medicine.  Retrieved from:  http://catalyst.nejm.org/how-multi-specialty-hubs-fill-a-major-gap-in-the-care-continuum/

Cheney, C.  (2016, June 20).  How bundled payments ratchet readmission rates downward.  HealthLeaders Media.  Retrieved from:  http://www.healthleadersmedia.com/finance/how-bundled-payments-ratchet-readmission-rates-downward

Larson, L.  (2016, June 10).  How community health workers can improve patient outcomes.  H&HN.  Retrieved from:  http://www.hhnmag.com/articles/7235-how-community-health-workers-can-improve-patient-outcomes\

Kliff, S.  (2016, June 1).  Unpaid, stressed, and confused:  patients are the health care system's free labor.  Vox Media, Inc. Retrieved from:  http://www.vox.com/2016/6/1/11712776/healthcare-footprint?_hsenc=p2ANqtz--3gujdEH_1C5l7CkxPYuODrIK-IMBNxUZipn8mZdaZsOKxQRVAVTdenT4OTxudoOwnHIH8ExSxck-barnzwpoH-UrLfw&_hsmi=30188607

Mace, S.  (2016, May 3).  At Houston Methodist, population health is the real deal.  HealthLeaders Media.  Retrieved from:  http://www.healthleadersmedia.com/technology/houston-methodist-population-health-real-deal

Rau, J.  (2016, May 2).  Hospital discharge:  It's one of the most dangerous periods for patients.  Kaiser Health News.  Retrieved from:  http://khn.org/news/home-health-agencies-often-miss-medication-errors-endangering-patients

Budryk, Z.  (2016, Apr. 22).  Best practices for care coordination [Special Report].  FierceHealthcare.  Retrieved from:  http://www.fiercehealthcare.com/special-reports/best-practices-care-coordination-special-report

Zuckerman, R., Sheingold, S., Orav, J., and others.  (2016, Apr. 21).  Readmissions, observation, and the hospital readmissions reduction program.  New England Journal of Medicine. 374:1543-1551.  Retrieved from:  http://www.nejm.org/doi/full/10.1056/NEJMsa1513024

Dale, S., Ghosh, A., and Peikes, D.  (2016, Apr. 13).  Two-year costs and quality in the comprehensive primary care initiative.  New England Journal of Medicine.  Retrieved from:  http://www.nejm.org/doi/pdf/10.1056/NEJMsa1414953

Luthra, S.  (2016, Apr. 11).  Hospitals eye community health workers to cultivate patients' successes.  Kaiser Health News.  Retrieved from:  http://khn.org/news/hospitals-eye-community-health-workers-to-cultivate-patients-successes/

(2016, Apr. 11).  Comprehensive Primary Care Plus (CPC+) Fact Sheet.  Baltimore, MD:  Centers for Medicare & Medicaid Services.  Retrieved from:  https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-04-11.html

Commins, J.  (2016, Apr. 6).  Readmissions penalties still don't account for patient demographics.  HealthLeaders Media.  Retrieved from:  http://www.healthleadersmedia.com/community-rural/readmissions-penalties-still-dont-account-patient-demographics#

Pecci, A.  (2016, Apr. 5).  Readmission prediction score validated in multi-country study.  HealthLeaders Media.  Retrieved from:  http://www.healthleadersmedia.com/quality/readmission-prediction-score-validated-multi-country-study

(2016, Apr.).  Patient Centered Medical Home Resource Center.  Rockville, MD:  Agency for Healthcare Research Center.  Retrieved from:  https://pcmh.ahrq.gov/

Gray, E., and Aronovich, R.  (2016, Apr.).  Producing an ROI with a patient-centered medical home.  Healthcare Financial Management.  Retrieved from:  https://www.hfma.org/Content.aspx?id=47225

Kroch, E., Duan, M., and Martin, J., and others.  (2016, Mar./Apr.).  Patient factors predictive of hospital readmissions withing 30 days.  Journal for Healthcare Quality.  38(2):106-115.  Retrieved from:  http://journals.lww.com/jhqonline/Abstract/2016/03000/Patient_Factors_Predictive_of_Hospital.7.aspx

Compton-Phillips, A.  (2016, Mar. 31).  Care redesign report:  Why population health management is undervalued.  New England Journal of Medicine Catalyst.  Retrieved from:  http://catalyst.nejm.org/care-redesign-report-why-population-health-management-is-undervalued/

Andrews, M.  (2016, Mar. 25).  Study:  Primary care doctors often don't help patients manage depression.  Kaiser Health News.  Retrieved from:  http://khn.org/news/primary-care-doctors-often-dont-help-patients-manage-depression-study/

Boyle, M.  (2016, Mar. 23).  Collaboration With Chronic Disease Groups Optimizers Outcomes for Payers and Patients.  Health Affairs Blog.  Retrieved from:  http://healthaffairs.org/blog/2016/03/23/collaboration-with-chronic-disease-groups-optimizes-outcomes-for-payers-and-patients/

Budryk, Z.  (2016, Mar. 17).  Healthcare miscommunications contribute to a quarter of readmissions.  FierceHealthcare.  Retrieved from:  www.fiercehealthcare.com/story/healthcare-miscommunications-contribute-quarter-readmissions/2016-03-17

Sisk, T.  (2016, Mar. 4).  Rural Hospitals embrace population health in quest for relevance.  North Carolina Health News.  Retrieved from:  www.northcarolinahealthnews.org/2016/03/04/rural-hospitals-embrace-population-health-in-quest-for-relevance/

Distel, E., Casey, M., and Prasad, S.  (2016, Mar.).  Reducing Potentially-Preventable Readmissions in Critical Access Hospitals.  Policy Brief #43.  The Flex Monitoring Team.  Retrieved from:  http://www.flexmonitoring.org/wp-content/uploads/2016/03/PB43-readmissions.pdf

(2016, Mar.).  Medicaid Accountable Care Organizations:  State Update.  Trenton, NJ:  CHCS Center for Health Care Strategies, Inc.  Retrieved from:  http://www.chcs.org/media/ACO-Fact-Sheet-032116.pdf

(2016, Mar.).  Creating Patient-Centered, Team-Based Primary Care.  Rockville, MD:  Agency for Healthcare Research Center. Retrieved from:  https://pcmh.ahrq.gov/page/creating-patient-centered-team-based-primary-care

Dickens, C., Weitzel, D., and Brown, S.  (2016, Mar.).  Mr. G and the revolving door:  Breaking the readmission cycle at a safety-net hospital.  Health Affairs.  35(3):540-543.  Retrieved from:  http://content.healthaffairs.org/content/35/3/540.abstract

Caspi, H.  (2016, Feb. 29).  HHS study finds reduced readmissions real, not masked as observation stays.  Healthcare Dive.  Retrieved from:  http://www.healthcaredive.com/news/hhs-study-finds-reduced-readmissions-real-not-masked-as-observation-stays/414654/

Zuckerman, R., Sheingold, S., Orav, J., and others.   (2016, Feb. 24).  Readmissions, observation, and the hospital readmissions reduction program.  New England Journal of Medicine.  Retrieved from:  http://www.nejm.org/doi/full/10.1056/NEJMsa1513024#t=articleTop

Commins, J.  (2016, Feb. 18).  Dartmouth atlas:  Evidence-based, coordinated care for seniors elusive.  HealthLeaders Media.  Retrieved from:  http://healthleadersmedia.com/print/QUA-325531/Dartmouth-Atlas-Evidencebased-Coordinated-Care-for-Seniors-Elusive

Bynum, J., Meara, E., Chang, C., and Rhoads, J.  (2016, Feb. 17).  Our Parents, Ourselves:  Health Care for an Aging Population.  LeBanon, NH:  Dartmouth Institute.  Retrieved from:  http://www.dartmouthatlas.org/downloads/reports/Our_Parents_Ourselves_021716_embargoed.pdf

Pecci, A.  (2016, Feb. 10).  A payer and a partner make the case for extensivists.  HealthLeaders Media.  Retrieved from:  http://healthleadersmedia.com/content.cfm?topic=HEP&content_id=325296

Mason, D.  (2016, Feb. 10).  JAMA forum:  Is 'firing" the patient an unintended consequence of value-based payment?  Journal of the American Medical Association.  Retrieved from:  http://newsatjama.jama.com/2016/02/10/jama-forum-is-firing-the-patient-an-unintended-consequence-of-value-based-payment/

Letourneau, R.  (2016, Feb. 10).  3 payer-driven strategies to transform care models.  HealthLeaders Media.  Retrieved from:  http://healthleadersmedia.com/content/HEP-325299/3-PayerDriven-Strategies-to-Transform-Care-Models

(2016, Feb.).  White Paper:  Developing Care Management Programs to Serve High-Need, High-Cost Populations.  St. Paul, MN:  Health Care Transformation Task Force.  Retrieved from:  http://static1.squarespace.com/static/548b623fe4b0991231a05ff0/t/56c64f55ab48de588bfd56ee/1455837017035/HCTTF_Care+Management+Programs+for+the+High-Cost+Patient+White+Paper.pdf

Nielsen, M., Buelt, L., Patel, K., and others.  (2016, Feb.).  The Patient-Centered Medical Home's Impact on Cost and Quality.  New York:  Milbank Memorial Fund.  Retrieved from:  https://www.pcpcc.org/sites/default/files/resources/The%20Patient-Centered%20Medical%20Home's%20Impact%20on%20Cost%20and%20Quality%2C%20Annual%20Review%20of%20Evidence%2C%202014-2015.pdf

Letourneau, R.  (2016, Jan. 20).  PCMH model soaring, despite funding challenges.  HealthLeaders Media.  Retrieved from:  http://healthleadersmedia.com/content/HEP-324683/PCMH-Model-Soaring-Despite-Funding-Challenges

DiChiara, J.  (2016, Jan. 19).  Accountable Care Organizations Renew Hospital Reimbursement; Accountable Care Organizations May Benefit Revenue Cycle Management, Especially for the Rural Hospital Community. Critical Access Hospitals May Even Become Profit Centers.  Danvers, MA:  Xtelligent Media, LLC.  Retrieved from:  http://revcycleintelligence.com/news/accountable-care-organizations-renew-hospital-reimbursement

(2016, Jan. 11).  Significant Costs Involved with Converting Primary Care Medical Practices to 'Medical Homes'.  Santa Monica, CA:  Rand Corp.  Retrieved from:  http://www.rand.org/news/press/2016/01/11.html

Sheingold, S., Zuckerman, R., Shartzer, A.  (2016, Jan).  Understanding Medicare hospital readmission rates and differing penalties between safety-net and other hospitals.  Health Affairs.  35(1):124-131.  Retrieved from:  http://content.healthaffairs.org/content/35/1/124.full 

Fu, N.  (2016).  Once A Cure;  Second A Waste.  Santa Monica, CA:  Rand Corporation.  Retrieved from:  http://www.rand.org/pubs/rgs_dissertations/RGSD366.html

(2016).  Committee on Educating Health Professionals to Address the Social Determinants of Health.  A Framework for Educating Health Professionals to Address the Social Determinants of Health.  Washington:  National Academies Press.  Retrieved from:  http://nap.us4.list-manage.com/track/click?u=eaea39b6442dc4e0d08e6aa4a&id=33ee4a72ba&e=36978ca720

(2016).  Committee and Accounting for Socioeconomic Status in Medicare Payment Programs and others.  Systems Practices for the Care of Socially At-Risk Populations.  Washington:  The National Academies Press.  Retrieved from:  http://www.nap.edu/catalog/21914/systems-practices-for-the-care-of-socially-at-risk-populations

(2016).  Social Determinants and Collaborative Health Care:  Improved Outcomes, Reduced Costs.  Chicago:  Deloitte.  Retrieved from:  https://www2.deloitte.com/content/dam/Deloitte/us/Documents/life-sciences-health-care/us-social-determinants-and-collaborative-health-care.pdf