Care Management Theories versus Realities in Health Care

References

• AHRQ. (2001). Experience of care and health outcomes (ECHO) survey: Revised managed behavioral healthcare organization version. Retrieved from http://www.ahrq.gov/cahps/about-cahps/index.html
   Google Scholar
• Allen, H. (2012). Is there a social worker in the house? Health care reform and the future of medical social work. Health & Social Work, 37(3), 183–186. doi:10.1093/hsw/hls021
   PubMed Web of Science ®Google Scholar
• Andrews, C. M., Darnell, J. S., McBride, T. D., & Gehlert, S. (2013). Social work and implementation of the affordable care act. Health & Social Work, 38(2), 67–71. doi:10.1093/hsw/hlt002
   PubMed Web of Science ®Google Scholar
• Beech, R., Henderson, C., Ashby, S., Dickinson, A., Sheaff, R., Windle, K., … Knapp, M. (2013). Does integrated governance lead to integrated patient care? Findings from the innovation forum. Health & Social Care in the Community, 21(6), 598–605. doi:10.1111/hsc.12042
   PubMed Web of Science ®Google Scholar
• Biernacki, P. J., Champagne, M. T., Peng, S., Maizel, D. R., & Turner, B. S. (2015). Transformation of care: Integrating the registered nurse care coordinator into the patient-centered medical home. Population Health Management, 18(5), 330–336. doi:10.1089/pop.2014.0131
   PubMed Web of Science ®Google Scholar
• Breckenridge, E. D., Kite, B., Wells, R., & Sunbury, T. (Forthcoming). Effect of patient care coordination on hospital use and related costs. Population Health Management.
   Google Scholar
• Bodenheimer, T., Lorig, K., Holman, H., & Grumbach, K. (2002). Patient self-management of chronic disease in primary care. Jama, 288(19), 2469–2475. doi:10.1001/jama.288.19.2469
   PubMed Web of Science ®Google Scholar
• Bongaerts, B. W., Müssig, K., Wens, J., Lang, C., Schwarz, P., Roden, M., & Rathmann, W. (2017). Effectiveness of chronic care models for the management of type 2 diabetes mellitus in Europe: A systematic review and meta-analysis. BMJ Open, 7(3), e013076. doi:10.1136/bmjopen-2016-013076
   PubMed Web of Science ®Google Scholar
• Carnochan, S., McBeath, B., & Austin, M. J. (2017). Managerial and frontline perspectives on the process of evidence-informed practice within human service organizations. Human Service Organizations: Management, Leadership & Governance, 41(4), 346–358.
   Web of Science ®Google Scholar
• Coleman, E. A., Parry, C., Chalmers, S., & Min, S.-J. (2006). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166(17), 1822–1828. doi:10.1001/archinte.166.17.1822
   PubMed Web of Science ®Google Scholar
• Coleman, E. A., Rosenbek, S. A., & Roman, S. P. (2013). Disseminating evidence-based care into practice. Population health Management, 16(4), 227-234. doi:10.1089/pop.2012.0069
   PubMed Web of Science ®Google Scholar
• Coleman, K., Austin, B. T., Brach, C., & Wagner, E. H. (2009). Evidence on the chronic care model in the new millennium. Health Affairs (millwood), 28(1), 75–85. doi:10.1377/hlthaff.28.1.75
   PubMed Web of Science ®Google Scholar
• Corbett, H. M., Lim, W. K., Davis, S. J., & Elkins, A. M. (2005). Care coordination in the emergency department: Improving outcomes for older patients. Australian Health Review, 29(1), 43–50.
   PubMedGoogle Scholar
• Darling, N. (2007). Ecological systems theory: The person in the center of the circles. Research in Human Development, 4(3–4), 203–217. doi:10.1080/15427600701663023
   Google Scholar
• Dy, S. M., Apostol, C., Martinez, K. A., & Aslakson, R. A. (2013). Continuity, coordination, and transitions of care for patients with serious and advanced illness: A systematic review of interventions. Journal of Palliative Medicine, 16(4), 436–445. doi:10.1089/jpm.2012.0317
   PubMed Web of Science ®Google Scholar
• Fisher, M. P., & Elnitsky, C. (2012). Health and social services integration: A review of concepts and models. Social Work in Public Health, 27(5), 441–468. doi:10.1080/19371918.2010.525149
   PubMed Web of Science ®Google Scholar
• Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., & Wallace, F. (2005). Implementation research: A synthesis of the literature. National Implementation Research Network at the Louis de la Parte Florida Mental Health Institute, University of South Florida.
   Google Scholar
• Freund, K. M. (2017). Implementation of evidence-based patient navigation programs. Acta Oncologica, 56(2), 123–127. doi:10.1080/0284186x.2016.1266078
   PubMed Web of Science ®Google Scholar
• Gazley, B. (2017). The current state of interorganizational collaboration: lessons for human service research and management: Taylor & Francis. Abingdon, UK.
   Google Scholar
• Golden, R. L. (2011). Coordination, integration, and collaboration: A clear path for social work in health care reform. Health & Social Work, 36(3), 227. doi:10.1093/hsw/36.3.227
   PubMed Web of Science ®Google Scholar
• Gorin, S. S., Haggstrom, D., Han, P. K., Fairfield, K. M., Krebs, P., & Clauser, S. B. (2017). Cancer care coordination: A systematic review and meta-analysis of over 30 years of empirical studies. Annals of Behavioral Medicine, 51(4), 532–546. doi:10.1007/s12160-017-9876-2
   PubMed Web of Science ®Google Scholar
• Greenhalgh, T., Robert, G., MacFarlane, F., Bate, P., & Kyriakidou, O. (2004). Diffusion of innovations in service organizations: Systematic review and recommendations. The Milbank Quarterly, 82(4), 581–629. doi:10.1111/j.0887-378X.2004.00325.x
   PubMed Web of Science ®Google Scholar
• Head, K. J., & Bute, J. J. (2018). The influence of everyday interpersonal communication on the medical encounter: An extension of street’s ecological model. Health Communication, 33(6), 1532–7027. doi:10.1080/10410236.2017.1306474
   Web of Science ®Google Scholar
• Hickam, D. H., Weiss, J. W., Guise, J.-M., Buckley, D., Motu’apuaka, M., Graham, E., … Saha, S. (2013). Outpatient case management for adults with medical illness and complex care needs. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ).
   Google Scholar
• Johnson, T. J., Jones, A., Lulias, C., & Perry, A. (2018). Practice innovation, health care utilization and costs in a network of federally qualified health centers and hospitals for medicaid. Population Health Management, 18(5), 330–336.
   Google Scholar
• Kaiser Family Foundation. (2017). State health facts. Author. Retrieved from statehealthfacts.org
   Google Scholar
• Kim, S. E., Michalopoulos, C., Kwong, R. M., Warren, A., & Manno, M. S. (2013). Telephone care management's effectiveness in coordinating care for medicaid beneficiaries in managed care: a randomized controlled study. Health Services Research, 48(5), 1730-1749. doi:10.1111/1475-6773.12060
   PubMed Web of Science ®Google Scholar
• Kutner, M., Greenburg, E., Jin, Y., & Paulsen, C. (2006). The health literacy of America’s adults: Results from the 2003 national assessment of adult literacy (NCES 2006-483). Washington, D.C.: National Center for Education Statistics.
   Google Scholar
• Kvale, E. A., Huang, C. H. S., Meneses, K. M., Demark‐Wahnefried, W., Bae, S., Azuero, C. B., … Ritchie, C. S. (2016). Patient‐centered support in the survivorship care transition: Outcomes from the patient‐owned survivorship care plan intervention. Cancer, 122(20), 3232–3242. doi:10.1002/cncr.30136
   PubMed Web of Science ®Google Scholar
• Lassman, D., Sisko, A. M., Catlin, A., Barron, M. C., Benson, J., Cuckler, G. A., … Whittle, L. (2017). Health spending by state 1991–2014: Measuring per capita spending by payers and programs. Health Affairs, 36, 7. doi:10.1377/hlthaff.2017.0416
   Web of Science ®Google Scholar
• Loskutova, N. Y., Tsai, A. G., Fisher, E. B., LaCruz, D. M., Cherrington, A. L., Harrington, T. M., … Pace, W. D. (2016). Patient navigators connecting patients to community resources to improve diabetes outcomes. Journal of the American Board of Family Medicine : JABFM, 29(1), 78–89. doi:10.3122/jabfm.2016.01.150048
   PubMed Web of Science ®Google Scholar
• Masters, S., Oliver‐Baxter, J., Barton, C., Summers, M., Howard, S., Roeger, L., & Reed, R. (2013). Programmes to support chronic disease self‐management: Should we be concerned about the impact on spouses? Health & Social Care in the Community, 21(3), 315–326. doi:10.1111/hsc.12020
   PubMed Web of Science ®Google Scholar
• McDonald, K. M., Sundaram, V., Bravata, D. M., Lewis, R., Lin, N., & Kraft, S. A., . . . Owens, D. K. (2007). Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Retrieved from Rockville, MD: https://www.ncbi.nlm.nih.gov/books/NBK44015/
   Google Scholar
• Nolte, E., Knai, C., & Saltman, R. B. (2014). Assessing chronic disease management in European health systems: European observatory on health systems and policies, Copenhagen, Denmark.
   Google Scholar
• Okin, R. L., Boccellari, A., Azocar, F., Shumway, M., O’brien, K., Gelb, A., … Wachsmuth, C. (2000). The effects of clinical case management on hospital service use among ED frequent users. The American Journal of Emergency Medicine, 18(5), 603–608. doi:10.1053/ajem.2000.9292
   PubMed Web of Science ®Google Scholar
• Parker, S., & Fuller, J. (2016). Are nurses well placed as care co‐ordinators in primary care and what is needed to develop their role: A rapid review? Health & Social Care in the Community, 24(2), 113–122. doi:10.1111/hsc.12194
   PubMed Web of Science ®Google Scholar
• Pearson, C., & Watson, N. (2018). Implementing health and social care integration in Scotland: Renegotiating new partnerships in changing cultures of care. Health & Social Care in the Community, 26(3), e396–e403. doi:10.1111/hsc.12537
   PubMed Web of Science ®Google Scholar
• Peters, S. C. (2017). Social work leadership: An analysis of historical and contemporary challenges. Human Service Organizations: Management, Leadership & Governance, 41(4), 336–345.
   Web of Science ®Google Scholar
• Reistroffer, C., Hearld, L. R., & Szychowski, J. M. (2017). An examination of the relationship between care management with coaching for activation and patient outcomes. The American Journal of Managed Care, 23(2), 123–128.
   PubMed Web of Science ®Google Scholar
• Rocque, G. B., Pisu, M., Jackson, B. E., Kvale, E. A., Demark-Wahnefried, W., Martin, M. Y., ...Acemgil, A. (2017). Resource use and medicare costs during lay navigation for geriatric patients with cancer. Jama Oncology, 3(6), 817-825.
   PubMed Web of Science ®Google Scholar
• Ross, A., Arnold, J., Gormley, A., Locke, S., Shanske, S., & Tardiff, C. (2019). Care coordination in pediatric health care settings: The critical role of social work. Social Work in Health Care, 58(1), 1–13. doi:10.1080/00981389.2018.1514352
   PubMed Web of Science ®Google Scholar
• Sangha, O., Stucki, G., Liang, M. H., Fossel, A. H., & Katz, J. N. (2003). The self‐administered comorbidity questionnaire: A new method to assess comorbidity for clinical and health services research. Arthritis Care & Research, 49(2), 156–163. doi:10.1002/art.10993
   Web of Science ®Google Scholar
• Seaberg, D., Elseroad, S., Dumas, M., Mendiratta, S., Whittle, J., Hyatte, C., & Keys, J. (2017). Patient navigation for patients frequently visiting the emergency department: A randomized, controlled trial. Academic Emergency Medicine, 24(11), 1327–1333. doi:10.1111/acem.13280
   PubMed Web of Science ®Google Scholar
• Shier, G., Ginsburg, M., Howell, J., Volland, P., & Golden, R. (2013). Strong social support services, such as transportation and help for caregivers, can lead to lower health care use and costs. Health Affairs, 32(3), 544–551. doi:10.1377/hlthaff.2012.0170
   Web of Science ®Google Scholar
• Sin, D. D., Bell, N. R., & Man, S. P. (2004). Effects of increased primary care access on process of care and health outcomes among patients with asthma who frequent emergency departments. The American Journal of Medicine, 117(7), 479–483. doi:10.1016/j.amjmed.2004.04.011
   PubMed Web of Science ®Google Scholar
• Soong, C., Kurabi, B., Wells, D., Caines, L., Morgan, M. W., Ramsden, R., & Bell, C. M. (2014). Do post discharge phone calls improve care transitions? A cluster-randomized trial. PloS One, 9(11), e112230. doi:10.1371/journal.pone.0112230
   PubMed Web of Science ®Google Scholar
• Southby, K., & Gamsu, M. (2018). Factors affecting general practice collaboration with voluntary and community sector organisations. Health & Social Care in the Community, 26(3), e360–e369. doi:10.1111/hsc.12538
   PubMed Web of Science ®Google Scholar
• StataCorp. (2015). Stata statistical software: Release 14.0. College Station, TX: Stata Corporation LP.
   Google Scholar
• Street, R. L., Gordon, H. W., Ward, M. M., Krupat, E., & Kravitz, R. L. (2005). Patient participation in medical consultations. Medical Care, 43(10), 960–969. doi:10.1097/01.mlr.0000178172.40344.70
   PubMed Web of Science ®Google Scholar
• Trivedi, D., Goodman, C., Gage, H., Baron, N., Scheibl, F., Iliffe, S., … Drennan, V. (2013). The effectiveness of inter‐professional working for older people living in the community: A systematic review. Health & Social Care in the Community, 21(2), 113–128. doi:10.1111/j.1365-2524.2012.01067.x
   PubMed Web of Science ®Google Scholar
• USDA. (2013). Rural-urban continuum codes. Retrieved from http://www.ers.usda.gov/data-products/rural-urban-continuum-codes/.aspx
   Google Scholar
• Wagner, E. H., Austin, B. T., Davis, C., Hindmarsh, M., Schaefer, J., & Bonomi, A. (2001). Improving chronic illness care: Translating evidence into action. Health Affairs, 20(6), 64–78. doi:10.1377/hlthaff.20.6.64
   PubMed Web of Science ®Google Scholar
• Wagner, E. H., Davis, C., Schaefer, J., Von Korff, M., & Austin, B. (1999). A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly, 7, 56–66.
   PubMedGoogle Scholar
• Wel, K. A. V. D., Dahl, E., & Bergsli, H. (2016). The Norwegian policy to reduce health inequalities: Key challenges. Nordisk Välfärdsforskning | Nordic Welfare Research, 1(01), 19–29. doi:10.18261/issn.2464-4161-2016-01-03ER
   Google Scholar
• Wells, R., Breckenridge, E. D., Siañez, M., Tamayo, L., Kum, H.-C., & Ohsfeldt, R. L. (Forthcoming). Self-reported quality, health, and cost-related outcomes of care coordination among patients with complex health needs. Population Health Management.
   Google Scholar
• Wells, S., Rozenblum, R., Park, A., Dunn, M., & Bates, D. W. (2014). Personal health records for patients with chronic disease: A major opportunity. Applied Clinical Informatics, 05(02), 416–429. doi:10.4338/ACI-2014-01-RA-0002
   Google Scholar
• Whitaker, B. G., Dahling, J. J., & Levy, P. (2007). The Development of a feedback environment and role clarity model of job performance. Journal of Management, 33(4), 570–591. doi:10.1177/0149206306297581
   Web of Science ®Google Scholar
• Williams, M. V., Baker, D. W., Parker, R. M., & Nurss, J. R. (1998). Relationship of functional health literacy to patients’ knowledge of their chronic disease: A study of patients with hypertension and diabetes. Archives of Internal Medicine, 158(2), 166–172. doi:10.1001/archinte.158.2.166
   PubMed Web of Science ®Google Scholar
• Wolf, M. S., Gazmararian, J. A., & Baker, D. W. (2005). Health literacy and functional health status among older adults. Archives of Internal Medicine, 165(17), 1946–1952. doi:10.1001/archinte.165.17.1946
   PubMed Web of Science ®Google Scholar
• Wong, F. K. Y., Chow, S., Chang, K., Lee, A., & Liu, J. (2004). Effects of nurse follow-up on emergency room revisits: A randomized controlled trial. Social Science & Medicine, 59(11), 2207–2218. doi:10.1016/j.socscimed.2004.03.028
   PubMed Web of Science ®Google Scholar
• Yin, R. (2013). Case study research: Design and methods (5th ed.). Thousand Oaks, CA: Sage Publications, Inc.
   Google Scholar
• You, E., Dunt, D., & Doyle, C. (2016). What is the role of a case manager in community aged care? A qualitative study in Australia. Health & Social Care in the Community, 24(4), 495–506. doi:10.1111/hsc.12238
   PubMed Web of Science ®Google Scholar