메뉴 건너뛰기




Volumn 18, Issue 2, 2014, Pages

Informatics' role in integrating population and patient-level knowledge to improve care transitions in complex chronic disease

Author keywords

Care coordination; Care transitions; Chronic disease; Health informatics; Population health; Severity of illness

Indexed keywords


EID: 84918525485     PISSN: 10899758     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Article
Times cited : (4)

References (52)
  • 2
    • 84855644165 scopus 로고    scopus 로고
    • Integrated telehealth and care management program for Medicare beneficiaries with chronic disease linked to savings
    • Baker, L. C., Johnson, S. J., Macaulay, D., & Birnbaum, H. (2011). Integrated telehealth and care management program for Medicare beneficiaries with chronic disease linked to savings. Health Affairs, 30, 1689-1697. doi: 10.1377/hlthaff.2011.0216
    • (2011) Health Affairs , vol.30 , pp. 1689-1697
    • Baker, L.C.1    Johnson, S.J.2    Macaulay, D.3    Birnbaum, H.4
  • 3
    • 33947539073 scopus 로고    scopus 로고
    • Informatics for patient safety: A nursing research perspective
    • Bakken, S. (2006). Informatics for patient safety: A nursing research perspective. Annual Review of Nursing Research, 24, 219-254.
    • (2006) Annual Review of Nursing Research , vol.24 , pp. 219-254
    • Bakken, S.1
  • 4
    • 70350438633 scopus 로고    scopus 로고
    • Translating clinical informatics interventions into routine clinical care: How can the RE-AIM framework help?
    • Bakken, S., & Ruland, C. M. (2009). Translating clinical informatics interventions into routine clinical care: How can the RE-AIM framework help? Journal of the American Medical Informatics Association, 16(6), 889-897. doi: 10.1197/jamia.M3085
    • (2009) Journal of the American Medical Informatics Association , vol.16 , Issue.6 , pp. 889-897
    • Bakken, S.1    Ruland, C.M.2
  • 5
    • 52049114461 scopus 로고    scopus 로고
    • A nursing informatics research agenda for 2008-18: Contextual influences and key components
    • Bakken, S., Stone, P. W., & Larson, E. L. (2008). A nursing informatics research agenda for 2008-18: Contextual influences and key components. Nursing Outlook, 56(5), 206-214.e203. doi: 10.1016/j.outlook.2008.06.007
    • (2008) Nursing Outlook , vol.56 , Issue.5 , pp. 206-214.e203
    • Bakken, S.1    Stone, P.W.2    Larson, E.L.3
  • 7
    • 44449101826 scopus 로고    scopus 로고
    • The triple aim: Care, health, and cost
    • Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The triple aim: Care, health, and cost. Health Affairs, 27(3), 759-769. doi: 10.1377/hlthaff.27.3.759
    • (2008) Health Affairs , vol.27 , Issue.3 , pp. 759-769
    • Berwick, D.M.1    Nolan, T.W.2    Whittington, J.3
  • 8
    • 59449090134 scopus 로고    scopus 로고
    • Confronting the growing burden of chronic disease: Can the US health care workforce do the job?
    • Bodenheimer, T., Chen, E., & Bennett, H. D. (2009). Confronting the growing burden of chronic disease: Can the US health care workforce do the job? Health Affairs, 28(1), 64-74. doi: 10.1377/hlthaff.28.1.64
    • (2009) Health Affairs , vol.28 , Issue.1 , pp. 64-74
    • Bodenheimer, T.1    Chen, E.2    Bennett, H.D.3
  • 9
    • 84855601565 scopus 로고    scopus 로고
    • Clinical effectiveness, access to, and satisfaction with care using a telehomecare substitution intervention: A randomized controlled trial
    • Bowles, K. H., Hanlon, A. L., Glick, H. A., Naylor, M. D., Riegel, B., Shih, N. W., & Weiner, M. G. (2011). Clinical effectiveness, access to, and satisfaction with care using a telehomecare substitution intervention: A randomized controlled trial. International Journal of Telemedicine and Applications, 2011, Article ID 540138, 13 pages. doi: 10.1155/2011/540138
    • (2011) International Journal of Telemedicine and Applications , vol.2011 , pp. 13
    • Bowles, K.H.1    Hanlon, A.L.2    Glick, H.A.3    Naylor, M.D.4    Riegel, B.5    Shih, N.W.6    Weiner, M.G.7
  • 11
    • 78650431963 scopus 로고    scopus 로고
    • Comparative effectiveness research and medical informatics
    • D'Avolio, L. W., Farwell, W. R., & Fiore, L. D. (2010). Comparative effectiveness research and medical informatics. The American Journal of Medicine, 123(12, Suppl.), e32-e37. doi: 10.1016/j.amjmed.2010.10.006
    • (2010) The American Journal of Medicine , vol.123 , Issue.12 , pp. e32-e37
    • D'Avolio, L.W.1    Farwell, W.R.2    Fiore, L.D.3
  • 12
    • 84857252981 scopus 로고    scopus 로고
    • Integrated systems and continuity in health care: A navigation through the concepts and models
    • DiStanislao, F., Visca, M., Caracci, G., & Moirano, F. (2011). Integrated systems and continuity in health care: A navigation through the concepts and models. Journal of Integrated Care Pathways, 15(3), 82-89. doi: 10.1258/jicp.2011.011008
    • (2011) Journal of Integrated Care Pathways , vol.15 , Issue.3 , pp. 82-89
    • DiStanislao, F.1    Visca, M.2    Caracci, G.3    Moirano, F.4
  • 13
    • 84858707487 scopus 로고    scopus 로고
    • Issue brief: Exploring the promise of population health management programs to improve health
    • Felt-Liks, S., & Higgins, T. (2011). Issue brief: Exploring the promise of population health management programs to improve health. Retrieved from http://www.mathematica-mpr.com/publications/pdfs/health/PHM_brief.pdf
    • (2011)
    • Felt-Liks, S.1    Higgins, T.2
  • 14
    • 16544395358 scopus 로고    scopus 로고
    • Population-based disease management under fee-for-service Medicare
    • W3-342-356
    • Foote, S. M. (2003). Population-based disease management under fee-for-service Medicare. Health Affairs, Suppl Web Exclusives, W3-342-356. doi: 10.1377/hlthaff.W3.342
    • (2003) Health Affairs, Suppl Web Exclusives
    • Foote, S.M.1
  • 15
    • 77957944109 scopus 로고    scopus 로고
    • HMC research translation: Speculations about makin it real and going to scale
    • Glasgow, R. (2010). HMC research translation: Speculations about makin it real and going to scale. American Journal of Health Behavior, 34(6), 833-840. doi: 10.5993/AJHB.34.6.17
    • (2010) American Journal of Health Behavior , vol.34 , Issue.6 , pp. 833-840
    • Glasgow, R.1
  • 16
    • 84857647420 scopus 로고    scopus 로고
    • Developing robust, sustainable, implementation systems using rigorous, rapid and relevant science
    • Glasgow, R. E., & Chambers, D. (2012). Developing robust, sustainable, implementation systems using rigorous, rapid and relevant science. Clinical and Translational Science, 5(1), 48-55. doi: 10.1111/j.1752-8062.2011.00383.x
    • (2012) Clinical and Translational Science , vol.5 , Issue.1 , pp. 48-55
    • Glasgow, R.E.1    Chambers, D.2
  • 17
    • 77955044695 scopus 로고    scopus 로고
    • Care management's challenges and opportunities to reduce the rapid rehospitalization of frail community-dwelling older adults
    • Golden, A. G., Tewary, S., Dang, S., & Roos, B. A. (2010). Care management's challenges and opportunities to reduce the rapid rehospitalization of frail community-dwelling older adults. Gerontologist, 50(4), 451-458. doi: 10.1093/geront/gnq015
    • (2010) Gerontologist , vol.50 , Issue.4 , pp. 451-458
    • Golden, A.G.1    Tewary, S.2    Dang, S.3    Roos, B.A.4
  • 18
    • 68249153473 scopus 로고    scopus 로고
    • Preventing the preventable: Reducing rehospitalizations through coordinated, patient-centered discharge processes
    • Greenwald, J. L., & Jack, B. W. (2009). Preventing the preventable: Reducing rehospitalizations through coordinated, patient-centered discharge processes. Professional Case Management, 14(3), 135-140. doi: 10.1097/NCM.0b013e318198d4e1
    • (2009) Professional Case Management , vol.14 , Issue.3 , pp. 135-140
    • Greenwald, J.L.1    Jack, B.W.2
  • 21
    • 79955090515 scopus 로고    scopus 로고
    • The community-based transitions model: One agency's experience
    • Hennessey, B., & Suter, P. (2011). The community-based transitions model: One agency's experience. Home Healthcare Nurse, 29(4), 218-232. doi: 10.1097/NHH.0b013e318211986d
    • (2011) Home Healthcare Nurse , vol.29 , Issue.4 , pp. 218-232
    • Hennessey, B.1    Suter, P.2
  • 22
    • 84918502750 scopus 로고    scopus 로고
    • A population-based care transition model for chronically ill elders
    • in press
    • Hewner, S. (in press). A population-based care transition model for chronically ill elders. Nursing Economic$.
    • Nursing Economic$.
    • Hewner, S.1
  • 23
    • 84918583766 scopus 로고    scopus 로고
    • Impact of Intervention Intensity on Health Outcomes in Medicaid Adults with Chronic Disease: Comparative Effectiveness Research Using Existing Clinical Electronic Data
    • Manuscript submitted for publication.
    • Hewner, S., Mehrok, N., Wu, Y. W., & Deloresco, F. (2014). Impact of Intervention Intensity on Health Outcomes in Medicaid Adults with Chronic Disease: Comparative Effectiveness Research Using Existing Clinical Electronic Data. Manuscript submitted for publication.
    • (2014)
    • Hewner, S.1    Mehrok, N.2    Wu, Y.W.3    Deloresco, F.4
  • 24
    • 33645078933 scopus 로고    scopus 로고
    • Development and validation of a screen for specialized discharge planning services
    • Holland, D. E., Harris, M. R., Leibson, C. L., Pankratz, V. S., & Krichbaum, K. E. (2006). Development and validation of a screen for specialized discharge planning services. Nursing Research, 55(1), 62-71.
    • (2006) Nursing Research , vol.55 , Issue.1 , pp. 62-71
    • Holland, D.E.1    Harris, M.R.2    Leibson, C.L.3    Pankratz, V.S.4    Krichbaum, K.E.5
  • 25
    • 80052297888 scopus 로고    scopus 로고
    • Problems and unmet needs of patients discharged "Home to Self-Care"
    • Holland, D. E., Mistiaen, P., & Bowles, K. H. (2011). Problems and unmet needs of patients discharged "Home to Self-Care". Professional Case Management, 16(5), 240-250. doi: 10.1097/NCM.0b013e31822361d8
    • (2011) Professional Case Management , vol.16 , Issue.5 , pp. 240-250
    • Holland, D.E.1    Mistiaen, P.2    Bowles, K.H.3
  • 26
    • 33644633715 scopus 로고    scopus 로고
    • System dynamics modeling for public health: Background and opportunities
    • Homer, J. B., & Hirsch, G. B. (2006). System dynamics modeling for public health: Background and opportunities. American Journal of Public Health, 96(3), 452-458. doi: 10.2105/AJPH.2005.062059
    • (2006) American Journal of Public Health , vol.96 , Issue.3 , pp. 452-458
    • Homer, J.B.1    Hirsch, G.B.2
  • 28
    • 63849134505 scopus 로고    scopus 로고
    • Rehospitalizations among patients in the Medicare fee-for-service program
    • Jencks, S. F., Williams, M. V., & Coleman, E. A. (2009). Rehospitalizations among patients in the Medicare fee-for-service program. New England Journal of Medicine, 360(14), 1418-1428. doi: 10.1056/NEJMsa0803563
    • (2009) New England Journal of Medicine , vol.360 , Issue.14 , pp. 1418-1428
    • Jencks, S.F.1    Williams, M.V.2    Coleman, E.A.3
  • 30
    • 84893538306 scopus 로고    scopus 로고
    • Connected health: A review of technologies and strategies to improve patient care with telemedicine and telehealth
    • Kvedar, J., Coye, M., & Everett, W. (2014). Connected health: A review of technologies and strategies to improve patient care with telemedicine and telehealth. Health Affairs, 33(2), 194-199. doi: 10.1377/hltaff.0992
    • (2014) Health Affairs , vol.33 , Issue.2 , pp. 194-199
    • Kvedar, J.1    Coye, M.2    Everett, W.3
  • 31
    • 34447282600 scopus 로고    scopus 로고
    • Using population segmentation to provide better health care for all: The "Bridges to Health" model
    • Lynn, J., Straube, B. M., Bell, K. M., Jencks, S. F., & Kambic, R. T. (2007). Using population segmentation to provide better health care for all: The "Bridges to Health" model. Milbank Quarterly, 85(2), 185-208. doi: 10.1111/j.1468-0009.2007.00483.x
    • (2007) Milbank Quarterly , vol.85 , Issue.2 , pp. 185-208
    • Lynn, J.1    Straube, B.M.2    Bell, K.M.3    Jencks, S.F.4    Kambic, R.T.5
  • 32
    • 84948711544 scopus 로고    scopus 로고
    • Integrating health information technology to achieve seamless care transitions
    • Advance online publication
    • Marcotte, L., Kirtane, J., Lynn, J., & McKethan, A. (2014). Integrating health information technology to achieve seamless care transitions. Journal of Patient Safety. Advance online publication. doi: 10.1097/pts.0000000000000077
    • (2014) Journal of Patient Safety
    • Marcotte, L.1    Kirtane, J.2    Lynn, J.3    McKethan, A.4
  • 33
    • 84861181403 scopus 로고    scopus 로고
    • Achieving meaningful use of health information technology: A guide for physicians to the EHR incentive programs
    • Marcotte, L., Seidman, J., Trudel, K., Berwick, D. M., Blumenthal, D., Mostashari, F., & Jain, S. H. (2012). Achieving meaningful use of health information technology: A guide for physicians to the EHR incentive programs. Archives of Internal Medicine, 172(9), 731-736. doi: 10.1001/archinternmed.2012.872
    • (2012) Archives of Internal Medicine , vol.172 , Issue.9 , pp. 731-736
    • Marcotte, L.1    Seidman, J.2    Trudel, K.3    Berwick, D.M.4    Blumenthal, D.5    Mostashari, F.6    Jain, S.H.7
  • 34
    • 34249291978 scopus 로고    scopus 로고
    • Information systems and case management practice series: Introduction to information systems and case management information system, part I (of III)
    • Mastrian, K., McGonigle, D., & Pavlekovsky, K. (2007). Information systems and case management practice series: Introduction to information systems and case management information system, part I (of III). Professional Case Management, 12(3), 181-183. doi: 10.1097/01.PCAMA.0000271370.31665.f1
    • (2007) Professional Case Management , vol.12 , Issue.3 , pp. 181-183
    • Mastrian, K.1    McGonigle, D.2    Pavlekovsky, K.3
  • 35
    • 33846308154 scopus 로고    scopus 로고
    • Advanced practice nurse strategies to improve outcomes and reduce cost in elders with heart failure
    • McCauley, K. M., Bixby, M. B., & Naylor, M. D. (2006). Advanced practice nurse strategies to improve outcomes and reduce cost in elders with heart failure. Disease Management, 9(5), 302-310. doi: 10.1089/dis.2006.9.302
    • (2006) Disease Management , vol.9 , Issue.5 , pp. 302-310
    • McCauley, K.M.1    Bixby, M.B.2    Naylor, M.D.3
  • 36
    • 57149126882 scopus 로고    scopus 로고
    • A multidisciplinary approach to transition care: A patient safety innovation study
    • McGaw, J., Conner, D., Delate, T., Chester, E., & Barnes, C. (2007). A multidisciplinary approach to transition care: A patient safety innovation study. The Permanente Journal, 11(4), 4-9.
    • (2007) The Permanente Journal , vol.11 , Issue.4 , pp. 4-9
    • McGaw, J.1    Conner, D.2    Delate, T.3    Chester, E.4    Barnes, C.5
  • 37
    • 84891470754 scopus 로고    scopus 로고
    • Continuity of care between family poractice physicians and hospitalist services
    • McMillan, A., Trompeter, J., Havrda, D., & Fox, J. (2013). Continuity of care between family poractice physicians and hospitalist services. Journal for Healthcare Quality, 35(1), 41-49. doi: 10.1111/j.1945-1474.2011.00165.x
    • (2013) Journal for Healthcare Quality , vol.35 , Issue.1 , pp. 41-49
    • McMillan, A.1    Trompeter, J.2    Havrda, D.3    Fox, J.4
  • 38
    • 79952327189 scopus 로고    scopus 로고
    • Linking home care interventions and hospitalization outcomes for frail and non-frail elderly patients
    • Monsen, K. A., Westra, B. L., Oancea, S. C., Yu, F., & Kerr, M. J. (2011). Linking home care interventions and hospitalization outcomes for frail and non-frail elderly patients. Research in Nursing & Health, 34(2), 160-168. doi: 10.1002/nur.20426
    • (2011) Research in Nursing & Health , vol.34 , Issue.2 , pp. 160-168
    • Monsen, K.A.1    Westra, B.L.2    Oancea, S.C.3    Yu, F.4    Kerr, M.J.5
  • 39
    • 70450172425 scopus 로고    scopus 로고
    • Data management for intervention effectiveness research: Comparing deductive and inductive approaches
    • Monsen, K. A., Westra, B. L., Yu, F., Ramadoss, V. K., & Kerr, M. J. (2009). Data management for intervention effectiveness research: Comparing deductive and inductive approaches. Research in Nursing & Health, 32(6), 647-656. doi: 10.1002/nur.20354
    • (2009) Research in Nursing & Health , vol.32 , Issue.6 , pp. 647-656
    • Monsen, K.A.1    Westra, B.L.2    Yu, F.3    Ramadoss, V.K.4    Kerr, M.J.5
  • 40
    • 84859045129 scopus 로고    scopus 로고
    • Advancing high value transitional care: The central role of nursing and its leadership
    • Naylor, M. D. (2012). Advancing high value transitional care: The central role of nursing and its leadership. Nursing Administration Quarterly, 36(2), 115-126. doi: 10.1097/NAQ.0b013e3182a040b
    • (2012) Nursing Administration Quarterly , vol.36 , Issue.2 , pp. 115-126
    • Naylor, M.D.1
  • 41
    • 79955575105 scopus 로고    scopus 로고
    • The importance of transitional care in achieving health reform
    • Naylor, M. D., Aiken, L. H., Kurtzman, E. T., Olds, D. M., & Hirschman, K. B. (2011). The importance of transitional care in achieving health reform. Health Affairs, 30(4), 746-754. doi: 10.1377/hltaff.2011.0041
    • (2011) Health Affairs , vol.30 , Issue.4 , pp. 746-754
    • Naylor, M.D.1    Aiken, L.H.2    Kurtzman, E.T.3    Olds, D.M.4    Hirschman, K.B.5
  • 43
    • 78149484799 scopus 로고    scopus 로고
    • Scaling up: Bringing the transitional care model into the mainstream
    • Naylor, M. D., & Sochalski, J. A. (2010). Scaling up: Bringing the transitional care model into the mainstream. Issue Brief (Commonw Fund), 103, 1-12.
    • (2010) Issue Brief (Commonw Fund) , vol.103 , pp. 1-12
    • Naylor, M.D.1    Sochalski, J.A.2
  • 44
    • 59449095442 scopus 로고    scopus 로고
    • Rising out-of-pocket spending for chronic conditions: A ten-year trend
    • Paez, K. A., Zhao, L., & Hwang, W. (2009). Rising out-of-pocket spending for chronic conditions: A ten-year trend. Health Affairs, 28, 15-25. doi: 10.1377/hlthaff.28.1.15
    • (2009) Health Affairs , vol.28 , pp. 15-25
    • Paez, K.A.1    Zhao, L.2    Hwang, W.3
  • 45
    • 80051574700 scopus 로고    scopus 로고
    • Managing multiple chronic conditions: A strategic framework for improving health outcomes and quality of life
    • Parekh, A. K., Goodman, R. A., Gordon, C., & Koh, H. K. (2011). Managing multiple chronic conditions: A strategic framework for improving health outcomes and quality of life. Public Health Reports, 126(4), 460-471.
    • (2011) Public Health Reports , vol.126 , Issue.4 , pp. 460-471
    • Parekh, A.K.1    Goodman, R.A.2    Gordon, C.3    Koh, H.K.4
  • 46
    • 77949404939 scopus 로고    scopus 로고
    • Further application of the care transitions intervention: Results of a randomized controlled trial conducted in a fee-for-service setting
    • Parry, C., Min, S., Chugh, A., Chalmers, S., & Coleman, E. A. (2009). Further application of the care transitions intervention: Results of a randomized controlled trial conducted in a fee-for-service setting. Home Health Care Services Quarterly, 28(2-3), 84-99. doi: 10.1080/01621420903155924
    • (2009) Home Health Care Services Quarterly , vol.28 , Issue.2-3 , pp. 84-99
    • Parry, C.1    Min, S.2    Chugh, A.3    Chalmers, S.4    Coleman, E.A.5
  • 47
    • 63449101834 scopus 로고    scopus 로고
    • Integrating care for persons, not only diseases
    • Peek, C. J. (2009). Integrating care for persons, not only diseases. Journal of Clinical Psychology in Medical Settings, 16(1), 13-20. doi: 10.1007/s10880-009-9154-y
    • (2009) Journal of Clinical Psychology in Medical Settings , vol.16 , Issue.1 , pp. 13-20
    • Peek, C.J.1
  • 48
    • 77951211793 scopus 로고    scopus 로고
    • Primary care for patient complexity, not only disease
    • Peek, C. J., Baird, M. A., & Coleman, E. (2009). Primary care for patient complexity, not only disease. Families, Systems, & Health, 27(4), 287-302. doi: 10.1037/a0018048
    • (2009) Families, Systems, & Health , vol.27 , Issue.4 , pp. 287-302
    • Peek, C.J.1    Baird, M.A.2    Coleman, E.3
  • 49
    • 84904046447 scopus 로고    scopus 로고
    • Fixing primary care: Insights from high-functioning practices in the comprehensive primary care initiative
    • R. Berenson (chair). Symposium conducted at the annual research meeting of the Academy Health, Baltimore, MD. June
    • Shapiro, R. (2013, June). Fixing primary care: Insights from high-functioning practices in the comprehensive primary care initiative. In R. Berenson (chair), Learning from the best: Fulfilling the potential of primary care. Symposium conducted at the annual research meeting of the Academy Health, Baltimore, MD.
    • (2013) Learning from the best: Fulfilling the potential of primary care
    • Shapiro, R.1
  • 50
    • 2442701417 scopus 로고    scopus 로고
    • The case for integrating public health informatics networks
    • Snee, N. L., & McCormick, K. A. (2004). The case for integrating public health informatics networks. Engineering in Medicine and Biology Magazine, IEEE, 23(1), 81-88. doi: 10.1109/memb.2004.1297178
    • (2004) Engineering in Medicine and Biology Magazine, IEEE , vol.23 , Issue.1 , pp. 81-88
    • Snee, N.L.1    McCormick, K.A.2
  • 51
    • 33749339052 scopus 로고    scopus 로고
    • The rise in spending among Medicare beneficiaries: The role of chronic disease prevalence and changes in treatment intensity
    • Thorpe, K. E., & Howard, D. H. (2006). The rise in spending among Medicare beneficiaries: The role of chronic disease prevalence and changes in treatment intensity. Health Affairs, 25(5), w378-w388. doi: 10.1377/hltaff.25.w378
    • (2006) Health Affairs , vol.25 , Issue.5 , pp. w378-w388
    • Thorpe, K.E.1    Howard, D.H.2
  • 52
    • 36448956057 scopus 로고    scopus 로고
    • Managing complexity in chronic care: An overview of the VA state-of-the-art (SOTA) conference
    • Weiss, K. B. (2007). Managing complexity in chronic care: An overview of the VA state-of-the-art (SOTA) conference. Journal of General Internal Medicine, 22(3), 374-378. doi: 10.1007/s11606-007-0379-x
    • (2007) Journal of General Internal Medicine , vol.22 , Issue.3 , pp. 374-378
    • Weiss, K.B.1


* 이 정보는 Elsevier사의 SCOPUS DB에서 KISTI가 분석하여 추출한 것입니다.