General Resource Links
Mi-CCSI - Michigan Center for Clinical Systems Improvement has some great free resources related to Care Management/Self-Management: http://www.miccsi.org/care-managementself-management-resources. For health systems that want to train newly hired Care Managers there are some resources and training sessions available: http://www.miccsi.org/training/care-management-team-based-care-optimizing-the-role-of-the-care-manager.
MiCMRC - The Michigan Care Management Resource Center (MiCMRC) website offers information, free training & webinars (including some with CE credits), and many other resources for care management teams (including this amazing Care Manager Activity Tracking Worksheet).
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.
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.
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. Abstract. Article.
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.