Case Management for Patients with Complex Multimorbidity: Development and Validation of a Coordinated Intervention between Primary and Hospital Care

Nolte E McKee M Ellen N Martin M Caring for people with chronic conditions: an introduction Caring for people with chronic conditions. A health system perspective 2008 McGraw-hill

World Health Organization Preventing chronic diseases: a vital investment 2005 Geneva, Switzerland WHO Press WHO Global report

Healy J-C Integration and Informatics and Communication Technologies (ICT) in the EU national health systems: status and trends Swiss Medical Informatics 2004 52 3 6 10.4414/smi.134.52.57

Committee on Quality of Health Care in America Institute of Medicine Crossing the quality chasm 2001 Washington, DC National Academy Press

Case Management Society of America Standards of Practice for Case Management 2010 Little Rock, Arkansas Case Management Society of America

Reid PP Building a Better Delivery System: A New Engineering/Health Care Partnership 2005 Washington, DC The National Academies Press

Woodward J Rice E Case Management Nursing Clinics of North America 2015 March 50 1 109 121 10.1016/j.cnur.2014.10.009

Ross S Curry N Goodwin N Case management. What it is and how can it best be implemented The King’s fund 2011 Available at: https://www.kingsfund.org.uk/sites/files/kf/Case-Management-paper-The-Kings-Fund-Paper-November-2011_0.pdf

Kumar GS Klein R Effectiveness of case management strategies in reducing emergency department visits in frequent user patient populations: a systematic review The Journal of Emergency Medicine 2013 March 44 3 717 729 10.1016/j.jemermed.2012.08.035

Fan VS Gaziano JM Lew R A comprehensive care management program to prevent chronic obstructive pulmonary disease hospitalizations: a randomized, controlled trial Annals of Internal Medicine 2012 May 156 10 673 683 10.7326/0003-4819-156-10-201205150-00003

Ferrante D Varini S Macchia A Long-Term Results After a Telephone Intervention in Chronic Heart Failure: DIAL (Randomized Trial of Phone Intervention in Chronic Heart Failure) Follow-Up Journal of the American College of Cardiology 2010 July 56 5 372 376 10.1016/j.jacc.2010.03.049

Clark RA Inglis SC McAlister FA Cleland JGF Simon S Telemonitoring or structured telephone support programmes for patients with chronic heart failure: systematic review and meta-analysis BMJ 2007 April 10 334 7600 942

You EC Dunt D Doyle C Hsueh A Effects of case management in community aged care on client and carer outcomes: a systematic review of randomized trials and comparative observational studies BMC Health Services Research 2012 November 12 395 10.1186/1472-6963-12-395

Huntley AL Thomas R Mann M Huws D Elwyn G Paranjothy S Purdy S Is case management effective in reducing the risk of unplanned hospital admissions for older people? A systematic review and meta-analysis Family Practice 2013 30 266 275 10.1093/fampra/cms081

Tinetti ME Fried TR Boyd CM Designing Health Care for the Most Common Chronic Condition—Multimorbidity JAMA 2012 307 2493 2494 10.1001/jama.2012.5265

Harrison C Britt H Miller G Henderson J Examining different measures of multimorbidity, using a large prospective cross-sectional study in Australia general practice BMJ Open 2014 4 e004694 1 9

Zulman DM Pal Chee C Wagner TH Yoon J Cohen DM Holmes TH Ritchie C Asch SM Multimorbidity and healthcare utilisation among high-cost patients in the US Veterans Affairs Health Care System BMJ Open 2015 5 4 1 10 e007771

Vogeli C Shields AE Lee TA Gibson TB Marder WD Weiss KB Blumenthal D Multiple Chronic Conditions: Prevalence, Health Consequences, and Implications for Quality, Care Management, and Costs Journal of General Internal Medicine 2007 22 S3 391 395 10.1007/s11606-007-0322-1

Goodwin N Sonola L Thiel V Kodner DL Co-ordinated care for people with complex chronic conditions. Key lessons and markers for success The King’s Fund 2013

Smith SM Wallace E O’Dowd T Fortin M Interventions for improving outcomes in patients with multimorbidity in primary care and community settings Cochrane Database of Systematic Reviews 2016 3 CD006560 1 91 10.1002/14651858.cd006560.pub3

Stokes J Panagioti M Alam R Checkland K Cheraghi-Sohi S Bower P Effectiveness of Case Management for ‘at risk’ patients in primary care: systematic review and meta-analysis PLOS One 2015 10 7 e0132340

The Effective Practice and Organisation of Care (EPOC) Group The EPOC taxonomy of health systems interventions 2015 Oslo Norwegian Knowledge Centre for the Health Services Available at: http://epoc.cochrane.org/epoc-specific-resources-review-authors

Harris AD Bradham DD Baumgarten M Zuckerman IH Fink JC Perencevich EN The use and interpretation of Quasi-experimental studies in infectious disease Antimicrobial resistance 2004 38 1586 91

Boren SA Wakefield BJ Gunlock TL Wakefield DS Heart failure self-management education: a systematic review of the evidence International Journal of Evidence-based Healthcare 2009 September 7 3 159 168 10.1111/j.1744-1609.2009.00134.x

Powell LH Calvin JE Richardson D Self-management counseling in patients with heart failure: the heart failure adherence and retention randomized behavioral trial JAMA 2010 304 12 1331 1338 10.1001/jama.2010.1362

Azzolin K Mussi CM Ruschel KB de Souza EN de Fátima Lucena A Rabelo-Silva ER Effectiveness of nursing interventions in heart failure patients in home care using NANDA-I, NIC, and NOC Applied Nursing Research 2013 26 4 239 244 10.1016/j.apnr.2013.08.003

Zwerink M Brusse-Keizer M van der Valk P Self management for patients with chronic obstructive pulmonary disease Cochrane Database of Systematic Reviews 2014 March 19 3 10.1002/14651858.cd002990.pub3

Health Quality Ontario In-home care for optimizing chronic disease management in the community: an evidence-based analysis Ontario Health Technology Assessment Series 2013 September 13 5 1 65

Freund T Baldauf A Muth C Gensichen J Szecsenyi J Peters-Klimm F Practice-based home visit and telephone monitoring of chronic heart failure patients: rationale, design and practical application of monitoring lists in the HICMan trial (English version) Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen 2011 105 6 434 445 10.1016/j.zefq.2010.06.027

Riegel B Carlson B Kopp Z LePetri B Glaser D Unger A Effect of a standardized nurse case-management telephone intervention on resource use in patients with chronic heart failure Archives of Internal Medicine 2002 March 162 6 705 712 10.1001/archinte.162.6.705

Yancy CW Jessup M Bozkurt B ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Journal of the American College of Cardiology 2013 October 62 16 e147 239 10.1016/j.jacc.2013.05.019

American Diabetes Association Standards of Medical Care in Diabetes—2014 Diabetes Care 2014 37 S1 S14 S80

Corrado OJ Hospital-at-Home Age and Ageing 2001 30 S3 11 14 10.1093/ageing/30.suppl_3.11

Sistrom CL Garvan CW Proportions, Odds and Risk Radiology 2004 230 12 19 10.1148/radiol.2301031028

Council for International Organizations of Medical Sciences International Ethical Guidelines for Epidemiological Studies 2009 Geneva, Switzerland The WHO Press

Shelton P Sager MA Schraeder C The community assessment risk screen (CARS): identifying elderly persons at risk for hospitalization or emergency department visit American Journal of Managed Care 2000 6 8 925 933

Effing T Monninkhof EEM van der Valk PPDLPM Zielhuis GGA Walters EH van der Palen JJ Zwerink M Self-management education for patients with chronic obstructive pulmonary disease Cochrane Database Systematic Review 2007 17 4 CD002990

Aguado O Morcillo C Delàs J Long-term implications of a single home-based educational intervention in patients with heart failure Heart & Lung: The Journal of Acute and Critical Care 2010 39 6 S14 S22 10.1016/j.hrtlng.2010.04.010

Corser W Dontje K Self-management perspectives of heavily comorbid primary care adults Professional Case Management 2011 16 1 6 15 10.1097/NCM.0b013e3181f508d0

Sutherland D Hayter M Structured review: evaluating the effectiveness of nurse case managers in improving health outcomes in three major chronic diseases Journal of Clinical Nursing 2009 18 21 2978 92 10.1111/j.1365-2702.2009.02900.x

Schraeder C Fraser CW Clark I Evaluation of a primary care nurse case management intervention for chronically ill community dwelling older people Journal of Nursing and Healthcare of Chronic Illness 2008 17 11C 407 417 10.1111/j.1365-2702.2008.02578.x

Lewis G Bardsley M Vaithianathan R Steventon A Georghiou T Billings J Dixon J Do ‘virtual wards’ reduce rates of unplanned hospital admissions, and at what cost? A research protocol using propensity matched controls International Journal of Integrated Care 2011 June 30 11 e079 10.5334/ijic.654

Fox JP Vashi AA Ross JS Gross CP Hospital-based, acute care after ambulatory surgery center discharge Surgery 2014 May 155 5 743 753 10.1016/j.surg.2013.12.008

Vashi AA Fox JP Carr BG D’Onofrio G Pines JM Ross JS Gross CP Use of Hospital-Based Acute Care Among Patients Recently Discharged From the Hospital JAMA 2013 January 309 4 364 371 10.1001/jama.2012.216219