General Resources

General Resource Links

Mi-CCSI - Michigan Center for Clinical Systems Improvement has some great free resources related to Care Management/Self-Management: For health systems that want to train newly hired Care Managers there are some resources and training sessions available:

MiCMRC - The Michigan Care Management Resource Center (MiCMRC) website offers informationfree training & webinars (including some with CE credits), and many other resources for care management teams (including this amazing Care Manager Activity Tracking Worksheet). 

Patient Ping: Real-time admissions and discharge notifications link providers anywhere patients receive care. Modern Healthcare: Article about Patient Ping

Michigan Health Information Network Shared Services: MiHIN’s ADT Notification Service enables the push exchange of Admit-Discharge-Transfer messages to doctors, specialists, therapists and other patient-authorized providers, using each provider’s preferred electronic notification method.

Medicare & Medicaid Statistical Supplement. Baltimore: Centers for Medicare & Medicaid Services, 2007. 

Agency for Healthcare Research and Quality (AHRQ)

National Institutes of Health (NIH)

National Quality Forum

Center to Advance Palliative Care

NQF Safe Practices

Northeastern College of Computer and Information Science

Project RED (Re-Engineered Discharge), Boston Medical Center

RI Quality Partner’s Safe Transitions Project

Plain Language in Healthcare

General Resource Articles

Recent Articles (Added 8/21):

Wan CS, Mitchell J, Maier AB. A Multidisciplinary, Community-Based Program to Reduce Unplanned Hospital Admissions. J Am Med Dir Assoc. 2021;22(6):1331.e1-1331.e9. doi:10.1016/j.jamda.2020.09.034. Abstract. Article

Prior Articles:

Amy E. Boutwell, Marian Bihrle Johnson, Patricia Rutherford, Sam R. Watson, Nancy Vecchioni, Bruce S. Auerbach, Paula Griswold, Patricia Noga and Carol Wagner
An Early Look At A Four-State Initiative To Reduce Avoidable Hospital Readmissions Health Affairs 30, no.7 (2011):1272-1280 doi:10.1377/hlthaff.2011.0111 Abstract. Article.

Auerbach AD, Kripalani S, Vasilevskis EE, Sehgal N, Lindenauer PK, Metlay JP, Fletcher G, Ruhnke GW, Flanders SA, Kim C, Williams MV, Thomas L, Giang V, Herzig SJ, Patel K, Boscardin WJ, Robinson EJ, Schnipper JL. Preventability and Causes of Readmissions in a National Cohort of General Medicine Patients. JAMA Intern Med. 2016;176(4):484-493. Article.

Bradley EH, Sipsma H, Curry L, Mehrotra D, Horwitz LI, Krumholz H, Hospitals Strategies to Reduce Readmissions. J. Hosp. Med 2013;11;601-608. doi:10.1002/jhm.2076 Article.

Dy SM, Ashok M, Wines RC, Rojas Smith L. A Framework to Guide Implementation Research for Care Transitions Interventions. Journal of Healthcare Quality. 2015;37(1):41-54. Abstract.

Dye C, Willoughby D, Aybar-Damali B, Grady C, Oran R, Knudson A. Improving Chronic Disease Self-Management by Older Home Health Patients through Community Health Coaching. Int J Environ Res Public Health. 2018 Apr 2;15(4):E660. AbstractArticle.

Hamar B, Rula EY, Wells AR, Coberley C, Pope JE, Varga D. Impact of a scalable care transitions program for readmission avoidance. Am J Manag Care. 2016 Jan;22(1):28-34. AbstractArticle.

Harlan M. Krumholz, M.D., Kun Wang, Ph.D., Zhenqiu Lin, Ph.D., Kumar Dharmarajan, M.D., Leora I. Horwitz, M.D., Joseph S. Ross, M.D., Elizabeth E. Drye, M.D., Susannah M. Bernheim, M.D., and Sharon-Lise T. Normand, Ph.D. Hospital-Readmission Risk — Isolating Hospital Effects from Patient Effects. N Engl J Med 2017; 377:1055-1064 September 14, 2017 DOI: 10.1056/NEJMsa1702321. Article.

Rico, Florentino; Liu, Yazhuo; Martinez, Diego A.; Huang, Shuai; Zayas-Castro, José L.; Fabri, Peter J. Preventable Readmission Risk Factors for Patients With Chronic Conditions. Journal for Healthcare Quality: May/June 2016 - Volume 38(3): 127-142  doi: 10.1097/01.JHQ.0000462674.09641.72 Abstract.  Article.

Robinson S, Howie-Esquivel J, Vlahov D. Readmission risk factors after hospital discharge among the elderly. Popul Health Manag. 2012 Dec;15(6):338-51. doi: 10.1089/pop.2011.0095. Abstract.

Rogers AT, Bai G, Lavin RA, Anderson GF. Higher Hospital Spending on Occupational Therapy Is Associated With Lower Readmission Rates. Med Care Res Rev. 2017 Dec;74(6):668-686. Abstract.

Wallace A, Papke T, Davisson E, Spooner K, Gassman L. Provider Opinions and Experiences Regarding Development of a Social Support Assessment to Inform Hospital Discharge: The Going Home Toolkit.  Prof Case Manag. 2017 Sep/Oct;22(5):214-227. Abstract.