Transitions of Care

Resources and References

Websites

  1. The National Transitions of Care Coalition www.ntocc.org/
  2. Stratis Health www.stratishealth.org
  3. The Care Transitions Program www.caretransitions.org
  4. The Society of Hospital Medicine www.hospitalmedicine.org/ResourceRoomRedesign/RR-CareTransitions/CT_Home.cfm
  5. The Joint Commission www.jointcommission.org/toc.aspx
  6. Institute for Healthcare Improvement www.ihi.org/knowledge/Pages/Tools/HowtoGuideImprovingTransitionstoReduceAvoidableRehospitalizations.aspx
  7. Transitions from Pediatric to Adult Health Care www.ndep.nih.gov/transitions

Articles

  1. Besdine R, Boult C, Brangman S, Coleman EA, Fried LP, Gerety M, Johnson JC, Katz PR, Potter JF, Reuben DB, Sloane PD, Studenski S, Warshaw G. American Geriatrics Society Task Force on the Future of Geriatric Medicine. Caring for Older Americans: the Future of Geriatric Medicine. Journal of the American Geriatrics Society. 53(6 Suppl):S245-56, 2005.
  2. Boult CE, Coleman EA. Diffusing Our Innovations. Journal of the American Geriatrics Society. 2003;51(1):127-128
  3. Boult C and Coleman EA. Response Letter to Drs. Boockvar and Vladeck. Journal of the American Geriatrics Society. 2004;52(5):856.
  4. Chalmers SA, Coleman EA. Transitional Care in Later Life: Improving the Move. Generations. Fall 2006:86-89.
  5. Chugh A, Williams MV, Grigsby J, Coleman EA. Better Transitions: Improving Comprehension of Discharge Instructions. Frontiers of Health Services Management. 2009; 25(3):11-32.
  6. Coleman EA, Barbaccia JC, Croughan-Minihane MS. Hospitalization Rates in Nursing Home Residents with Dementia: A Pilot Study of the Impact of a Special Care Unit. Journal of the American Geriatrics Society. 1990;38(2):108-12.
  7. Coleman EA, Wagner EH, Grothaus LC, Hecht J, Savarino J and Buchner DM. Predicting Hospitalization and Functional Decline in Older Health Plan Enrollees: Are Administrative Data as Accurate as Self-Report? Journal of the American Geriatrics Society. 1998; 46:419-25.
  8. Coleman EA, and Berenson RA. Lost in Transition: Challenges and Opportunities for Improving the Quality of Transitional Care. Annals of Internal Medicine. 2004;140:533-536.
  9. Coleman EA, Kramer AM, Kowalsky JC, Eckhoff D, Lin, M, Hester EJ, Morgenstern N, Steiner JF. A Comparison of Functional Outcomes after Hip Fracture in Group/Staff HMOs and Fee-for- Service Systems. Effective Clinical Practice (An ACP/ASIM Publication). 2000; 4:229-239.
  10. Coleman EA, Magid DJ, Beck A, Eilertsen TB, Conner D, Kramer AM. Reducing Emergency Visits in Older Adults with Chronic Illness: A Randomized Controlled Trial of Group Visits. Effective Clinical Practice (An ACP/ASIM Publication). 2001;(2):49-57.
  11. Coleman EA, Smith JD, Eilertsen TB, Frank JC, Thiare JN, Ward A, and Kramer AM. Development and Testing of a Measure Designed to Assess the Quality of Care Transitions. International Journal of Care Integration. 2002:2 April-June.
  12. Coleman EA. Challenges of Systems of Care for Frail Older Persons: The United States of America Experience. Aging Clinical Experimental Research. 2002;14(4):233-238.
  13. Coleman EA, Eilertsen TB, Magid DJ, Conner DM, Beck A, Kramer AM. The Association Between Care Coordination and Emergency Department Use in Older Managed Care Enrollees. International Journal of Care Integration. 2002:2 October-December.
  14. Coleman EA, Boult CE on behalf of the American Geriatrics Society Health Care Systems Committee. Improving the Quality of Transitional Care for Persons with Complex Care Needs. Journal of the American Geriatrics Society. 2003;51(4):556-557. 11.
  15. Coleman EA. Falling Through the Cracks: Challenges and Opportunities for Improving Transitional Care for Persons with Continuous Complex Care Needs. Journal of the American Geriatrics Society. 2003;51(4):549-555.
  16. Coleman EA, Min S, Chomiak A, Kramer AM. Post-Hospital Care Transitions: Patterns, Complications, and Risk Identification. Health Services Research. 2004; 37(5):1423-1440.
  17. Coleman, EA, and Fox PD on behalf of the HMO Care Management Workgroup. One Patient, Many Places: Managing Healthcare Transitions. Part I: Introduction, Accountability, and Information Transfer. Annals of Long-Term Care. 2004;12(9):25-32. Coleman EA, and Fox PD on behalf of the HMO Care Management Workgroup. One Patient, Many Places: Managing Healthcare Transitions. Part II: Practitioner Skills and Patient and Caregiver Preparation. Annals of Long-Term Care. 2004;12(10):34-39.
  18. Coleman EA, Smith JD, Frank JC, Min S, Parry C, Kramer AM. Preparing Patients and Caregivers to Participate in Care Delivered Across Settings: The Care Transitions Intervention. Journal of the American Geriatrics Society. 2004;52(11):1817-1825.
  19. Coleman EA, and Fox PD on behalf of the HMO Care Management Workgroup. One Patient, Many Places: Managing Healthcare Transitions. Part III: Financial Incentives and Getting Started. Annals of Long-Term Care. 2004;12(11):14-16.
  20. Coleman EA, Mahoney E, Parry C. Assessing the Quality of Preparation for Post-Hospital Care from the Patient’s Perspective: The Care Transitions Measure. Medical Care. 2005;43(3):246- 255.
  21. Coleman EA, Smith JD, Raha D, Min SJ. Post-Hospital Medication Discrepancies: Prevalence, Types and Contributing Factors. Arch of Int Med 2005;165(16)1842-1847.
  22. Coleman EA, Parry C, Chalmers S, Min SJ. The Care Transitions Intervention: Results of a Randomized Controlled Trial Archives of Internal Medicine. 2006; 166:1822-8.
  23. Coleman EA, Parry C, Chalmers S, Chugh A, Mahoney E. The Central Role of Performance Measurement in Improving the Quality of Transitional Care. Home Health Care Services Quarterly. 2007;000-000
  24. Coleman EA. How Can We Ground The Frequent Fliers? Journal of the American Geriatrics Society. 2007;55(3):467-468. Coleman EA, Williams MV. Executing High Quality Care Transitions: A Call to Do It Right. Journal of Hospital Medicine. 2007; 2(5):287-290.
  25. Coleman E, Parry C, Chambers S, Min S: The Care Transitions Intervention Arch Intern Med. 2006; 1822-1828
  26. Gittel JH. Fairfield K, Bierbaum B, Head W, Jackson R, Kelly M, Laskin R, Lipson S, Siliski J, Thornhill T, Zuckerman J: Impact of relational coordination on quality of care, post operative pain and functioning, and the length of stay: a nine hospital study of surgical patients. Med Care 38: 807-819, 2000
  27. Gloth III FM, Coleman EA, Phillips SL, Zorowitz RA. Using Electronic Health Records to Improve Care: Will “High Tech” Allow a Return to “High Touch” Medicine? Journal of the American Medical Directors Association. 2005;6: 270-5.
  28. Halasyamani L, Kripalani S, Coleman EA, Schnipper J, van Walraven C, Nagamine J, Torcson P, Bookwalter T, Budnitz T, Manning D. Transition of care for hospitalized elderly – the development of a Discharge Checklist for Hospitalists. Journal of Hospital Medicine. 2006;(1):354-360.
  29. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting Effective Transitions of Care at Hospital Discharge: A Review of the Literature. Journal of Hospital Medicine. 2007; 2(5):314- 323.Ma E, Coleman EA, Fish R, Lin M, and Kramer AM. Quantifying Post-Hospital Care Transitions in Older Patients. Journal of the American Medical Directors Association. 2004;5(2):71-74.
  30. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA 2007; 297:831-41.
  31. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: A review of key issues for hospitalists. J Hosp Med 2008; 2:314-323.
  32. Naylor M, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, Pauley M. Comprehensive discharge planning for the hospitalized elderly. Ann Intern Med. 1994; 120:999-1006.
  33. Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauley MV, Schwartz JS. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999; 281:613-620.
  34. Naylor MD, Brooten DA, Campell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004; 52:675-684.
  35. Naylor, M.D., Aiken, L.H., Kurtzman, E.T., Olds, D.M. & Hirschman, K.B. The importance of transitional care in achieving Health Reform. Health Affairs 2011;30(4):746-754.
  36. Naylor, M. Transitional Care: A Critical Dimension of the Home Healthcare Quality Agenda. Journal for Healthcare Quality 2006;8(1):48-55
  37. Naylor M, McCauley K: The effects of a discharge planning and home follow-up intervention on elderly hospitalized with common medical and surgical cardiac conditions. J Cardiovasc Nurs. 1999; 14 (1): 44-54.
  38. Parry C, Coleman EA, Smith JD, Frank JC, Kramer AM. The Care Transitions Intervention: A Patient-Centered Approach to Facilitating Effective Transfers Between Sites of Geriatric Care. Home Health Services Quarterly. 2003;22(3):1-18.
  39. Parry C, Kramer H, Coleman EA. A Qualitative Exploration of a Patient-Centered Coaching Intervention to Improve Care Transitions in Chronically Ill Older Adults. Home Health Care Services Quarterly. 2006;25(3-4):39
  40. Parry C, Mahoney E, Chalmers S, Coleman EA. Assessing the Quality of Transitional Care: Further Applications of the Care Transitions Measure. Medical Care. 2008(3):000-000. Abstract
  41. Parry, C., Mahoney, E., Chalmers, S.A. and Coleman, E.A. 2008. Assessing the quality of transitional care further applications of the care transitions measure. Medical Care. 2008(3):317-322.
  42. Peters, A, Laffel, L., ADA Transitions Working Group.. Diabetes Care for Emerging Adults: Recommendations for Transition From Pediatric to Adult Diabetes Care Systems. Diabetes Care 2011; 34: 2477-2485
  43. Philips CO. Comprehensive discharge planning with postdischarge support for older patients with congestive heaSimon, SR, Lee, TH, et, al. Communication problems for patients hospitalized with chest pain. J Gen Intern Med. 1998 Dec; 13(12):836-8.
  44. Preen D, Bailey B, Wright A, et al. Effects of a multidisciplinary, post-discharge continuance of care intervention on quality of life, discharge satisfaction, and hospital length of stay: a randomized controlled trial. Int J Qual Health Care. 2005; Feb 17(1):43-51.
  45. Improving care transitions and reducing hospital readmissions: Establishing the evidence for community-based implementation strategies through the care transitions theme, (Remington Report, January 2010)
  46. Rice K, Coleman EA, Fish R, Levy C, Kutner JS. Factors Influencing Models of End-of-Life Care in Nursing Homes. Journal of Palliative Medicine. 2004;7(5):668-675.
  47. Smith JD, Coleman EA, Min S. Identifying Post-Acute Medication Discrepancies in Community Dwelling Older Adults: A New Tool. American Journal of Geriatric Pharmacotherapy. 2004;2(2):141-148.
  48. van Walraven, c, Mamdani, M, et, al. Continuity of care and patient outcomes after hospital discharge. J Gen Intern Med. 2004 Jun; 19(6):624-31

Books & Reports

  1. Coleman EA (Editor). Charting a Course for High Quality Care Transitions. Haworth Press. New York. 2007.
  2. Coleman, EA and the Care Management Workgroup. One Patient, Many Places: Managing Healthcare Transitions. A Report from the Robert Wood Johnson Care Management Workgroup. February 2004.

Book Chapters

  1. Coleman EA and Besdine RW. “Integrating Quality Assurance Across the Sites of Geriatric Care.” In Calkins E, Wagner EH, Boult C, and Pacala J (Eds) New Ways to Care for Older People: Building Systems Based on Evidence. New York: Springer 1998.
  2. Coleman EA. “Organization of Health Care Across the Continuum of Care.” Chapter 13. In Hazzard WR et al. Principles of Geriatric Medicine and Gerontology. Fifth Edition. New York: McGraw-Hill 2002:145-156.
  3. Lyons W and Coleman EA. “Transitional Care.” In Duthie, Katz, and Malone (Eds). Practice of Geriatrics. Fourth Edition. Philadelphia: Elsevier 2006.
  4. Kripalani S, Trobaugh A, Coleman EA. “Hospital Discharge.” In Williams MV. Comprehensive Hospital Medicine. First Edition. 2007.
  5. Chalmers S and Coleman EA. “Transitional Care.” In Siegler E, Mezey M. Encyclopedia of Eldercare. 2007.
  6. Lyons W and Coleman EA. “Transitional Care.” In Hazzard WR et al. Principles of Geriatric Medicine and Gerontololgy. Sixth Edition. New York: McGraw-Hill 2007:00-00.

Policy Reports

  1. Coleman EA. Transitional Care Performance Measurement. In Institute of Medicine. Performance Measurement: Accelerating Improvement. National Academy of Sciences Press. Washington DC. December 2005.
  2. Coleman EA, May K, Bennett RE. Health Information Exchange in Post Acute and Long Term Care – Task 5.0 Report on HIE in Post-Acute and Long-Term Care. Department of Health and Human Services Assistant Secretary for Planning and Evaluation. Contract #100-03-0028.
  3. Bennett RE, Tuttle M, May K, Harvell J, Coleman EA. Health Information in Post-Acute and Long-Term Care: Case Study Findings (Final Report). Department of Health and Human Services Assistant Secretary for Planning and Evaluation. Contract #100-03-0028.