- Coleman EA, Parry C, Chalmers S, Min S-j The Care Transitions Intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822–1828. doi:10.1001/archinte.166.17.1822.
- Hall MJ, DeFrances CJ, Williams SN, Golosinskiy A, Schwartzman A. National Hospital Discharge Survey: 2007 summary. Natl Health Stat Report. 2010;24(29):1–20.
- Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation. 2014;129(3):e28–e292. doi:10.1161/01.cir.0000441139.02102.80.
- Peikes D, Jenevro G, Scholle S, Torda P. The Patient-Centered Medical Home: Strategies to Put Patients at the Center of Primary Care. Rockville, MD: Agency for Healthcare Research and Quality; 2011. https://www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/strategies-to-put-patients-at-center-of-primary-care-brief.pdf. 2011.
- Sherman RO. The patient engagement imperative. American Nurse Today. 2014;9(2):1–4. https://www.myamericannurse.com/the-patient-engagement-imperative/#:∼:text=Nurses%20must%20embrace%20and%20support,own%20health%20and%20health%20care.
- Institute for Health Technology Transformation. A Roadmap for Provider-Based Automation in a New Era of Healthcare. 2012. https://www.exerciseismedicine.org/assets/page_documents/PHM%20Roadmap%20HL.pdf.
- Viswanathan M, Golin CE, Jones CD, et al. Closing the quality gap: revisiting the state of the science (vol. 4: medication adherence interventions: comparative effectiveness). Evid Rep Technol Assess (Full Rep). 2012;(208.4):1–685.
- Murray MD, Young J, Hoke S, et al. Pharmacist intervention to improve medication adherence in heart failure: a randomized trial. Ann Intern Med. 2007;146(10):714–725. doi:10.7326/0003-4819-146-10-200705150-00005.
- Jovicic A, Holroyd-Leduc JM, Straus SE. Effects of self-management intervention on health outcomes of patients with heart failure: a systematic review of randomized controlled trials. BMC Cardiovasc Disord. 2006;6(1):43. doi:10.1186/1471-2261-6-43.
- National Health Priority Action Council. National Chronic Disease Strategy and the Frameworks. Canberra, Australia: Department of Health and Aging; 2006.
- World Health Organization. WHO Guidelines on Hand Hygiene in Health Care. 2009. https://www.who.int/publications/i/item/9789241597906.
- Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA. 2002;288(19):2469–2475. doi:10.1001/jama.288.19.2469.
- McAlister FA, Stewart S, Ferrua S, McMurray JJ. Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials. J Am Coll Cardiol. 2004;44(4):810–819. doi:10.1016/j.jacc.2004.05.055.
- Brown VA, Bartholomew LK, Naik AD. Management of chronic hypertension in older men: an exploration of patient goal-setting. Patient Educ Couns. 2007;69(1-3):93–99. doi:10.1016/j.pec.2007.07.006.
- Heisler M, Vijan S, Anderson RM, Ubel PA, Bernstein SJ, Hofer TP. When do patients and their physicians agree on diabetes treatment goals and strategies, and what difference does it make? J Gen Intern Med. 2003;18(11):893–902. doi:10.1046/j.1525-1497.2003.21132.x.
- Pearson ES. Goal setting as a health behavior change strategy in overweight and obese adults: a systematic literature review examining intervention components. Patient Educ Couns. 2012;87(1):32–42. doi:10.1016/j.pec.2011.07.018.
- Reuben DB, Tinetti ME. Goal-oriented patient care—an alternative health outcomes paradigm. N Engl J Med. 2012;366(9):777–779. doi:10.1056/NEJMp1113631.
- Strecher VJ, Seijts GH, Kok GJ, et al. Goal setting as a strategy for health behavior change. Health Educ Q. 1995;22(2):190–200. doi:10.1177/109019819502200207.
- Albert NM. Parallel paths to improve heart failure outcomes: evidence matters. Am J Crit Care. 2013;22(4):289–296. doi:10.4037/ajcc2013212.
- Schwarz KA, Elman CS. Identification of factors predictive of hospital readmissions for patients with heart failure. Heart Lung. 2003;32(2):88–99. doi:10.1067/mhl.2003.15.
- Riegel B, Lee CS, Dickson VV, Carlson B. An update on the self-care of heart failure index. J Cardiovasc Nurs. 2009;24(6):485–497. doi:10.1097/JCN.0b013e3181b4baa0.
- University of Washington Health Promotion Research Center. Rapid Assessment of Physical Activity (RAPA). Seattle, WA: University of Washington; 2006.
- Lorig KR, Sobel DS, Ritter PL, Laurent D, Hobbs M. Effect of a self-management program on patients with chronic disease. Eff Clin Pract. 2001;4(6):256–262.
- Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System (BRFSS) Questionnaire—Healthy Days Core Module (CDC HRQOL– 4). Atlanta, GA: US Department of Health and Human Services; 2004.
Baylor University Medical Center Proceedings
The peer-reviewed journal of Baylor Scott & White Health
Volume 37, 2024 - Issue 2
Original Research: Cardiology and Cardiac Surgery
Impact of a transitional care program for heart failure patients at Baylor Scott & White Health: a pilot study
Sitara H. Abrahama Center for Applied Health Research, Baylor Scott & White Research Institute, Temple, Texas, USA
https://orcid.org/0000-0002-8569-1298View further author information
, MPHhttps://orcid.org/0000-0002-8569-1298View further author information, , LMSW, , FNP, , LMSW, , BS, , PhD, , PhD, , PhD, MPH & , PhD show all