Cohen S, Yu W. The concentration and persistence in the level of health expenditures over time: estimates for the U.S. Population, 2008–2009. Statistical Brief #354 Agency for Healthcare Research and Quality, Rockville, MD 2012.
Hong CS, Siegel AL, Ferris TG. Caring for high-need, high-cost patients: what makes for a successful care management program? Issue Br. 2014;19:1–19.
Wensing M, Vingerhoets E, Grol R. Functional status, health problems, age and comorbidity in primary care patients. Qual Life Res Int J Qual Life Asp Treat Care Rehabilit. 2001;10:141–8.
Vogeli C, Shields AE, Lee TA, et al. Multiple chronic conditions: prevalence, health consequences, and implications for quality, care management, and costs. J Gen Intern Med. 2007;22(Suppl 3):391–5.
Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138:161–7.
Freund T, Wensing M, Mahler C, et al. Development of a primary care-based complex care management intervention for chronically ill patients at high risk for hospitalization: a study protocol. Implement Sci IS. 2010;5:70.
Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150:178–87.
Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166:1822–8.
Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281:613–20.
Kangovi S, Barg FK, Carter T, Long JA, Shannon R, Grande D. Understanding why patients of low socioeconomic status prefer hospitals over ambulatory care. Health Aff. 2013;32:1196–203.
Hong CS, Abrams MK, Ferris TG. Toward increased adoption of complex care management. N Engl J Med. 2014;371:491–3.
Yee T, Lechner, AE., Carrier E. High-intensity primary care: lessons for physician and patient engagement. (National Institute for Health Care Reform Research Brief No 9). http://www.nihcrorg/High-Intensity-Primary-Care. Accessed Nov 12, 2015 2012.
Edwards ST, Peterson K, Chan B, Anderson J, Helfand M. Effectiveness of intensive primary care interventions: a systematic review. J Gen Intern Med 2017;32:1377–86.
O’Toole TP, Johnson EE, Aiello R, Kane V, Pape L. Tailoring care to vulnerable populations by incorporating social determinants of health: the veterans health administration’s “homeless patient aligned care team” program. Prev Chronic Dis. 2016;13:E44.
Hunter G, Yoon J, Blonigen DM, Asch SM, Zulman DM. Health care utilization patterns among high-cost VA patients with mental health conditions. Psychiatr Serv. 2015;66:952–8.
London JA, Utter GH, Battistella F, Wisner D. Methamphetamine use is associated with increased hospital resource consumption among minimally injured trauma patients. J Trauma. 2009;66:485–90.
Hwang AS, Atlas SJ, Hong J, et al. Defining team effort involved in patient care from the primary care physician’s perspective. J Gen Intern Med. 2017;32:269–76.
Davis MM, Keller S, DeVoe JE, Cohen DJ. Characteristics and lessons learned from practice-based research networks (PBRNs) in the United States. J Healthc Leadersh. 2012;4:107–16.
Greene SM, Reid RJ, Larson EB. Implementing the learning health system: from concept to action. Ann Intern Med. 2012;157:207–10.
Chang ET, Zulman DM, Asch SM, et al. An operations-partnered evaluation of care redesign for high-risk patients in the Veterans Health Administration (VHA): study protocol for the PACT Intensive Management (PIM) randomized quality improvement evaluation. Contemp Clin Trials. 2018;69:65–75.
Handley MA, Schillinger D, Shiboski S. Quasi-experimental designs in practice-based research settings: design and implementation considerations. J Am Board Family Med JABFM. 2011;24:589–96.
Ratanawongsa N, Handley MA, Quan J, et al. Quasi-experimental trial of diabetes self-management automated and real-time telephonic support (SMARTSteps) in a medicaid managed care plan: study protocol. BMC Health Serv Res. 2012;12:22.
Englander H, Michaels L, Chan B, Kansagara D. The care transitions innovation (C-TraIn) for socioeconomically disadvantaged adults: results of a cluster randomized controlled trial. J Gen Intern Med 2014;29:1460–7.
Englander H, Weimer M, Solotaroff R, et al. Planning and designing the improving addiction care team (IMPACT) for hospitalized adults with substance use disorder. J Hosp Med Off Publ Soc Hosp Med. 2017;12:339–42.
Use the Teach-Back Method: Tool #5. Agency for Healthcare Research and Quality, Rockville, MD.
Boutron I, Moher D, Altman DG, Schulz KF, Ravaud P, Group C. Extending the CONSORT statement to randomized trials of nonpharmacologic treatment: explanation and elaboration. Ann Intern Med. 2008;148:295–309.
Shippee ND, Shah ND, May CR, Mair FS, Montori VM. Cumulative complexity: a functional, patient-centered model of patient complexity can improve research and practice. J Clin Epidemiol. 2012;65:1041–51.
Hibbard JH, Mahoney ER, Stockard J, Tusler M. Development and testing of a short form of the patient activation measure. Health Serv Res. 2005;40:1918–30.
Hibbard JH, Stockard J, Mahoney ER, Tusler M. Development of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Serv Res. 2004;39:1005–26.
Centers for M, Medicaid Services HHS. Medicare program; hospital outpatient prospective payment system and CY 2007 payment rates; CY 2007 update to the ambulatory surgical center covered procedures list; Medicare administrative contractors; and reporting hospital quality data for FY 2008 inpatient prospective payment system annual payment update program–HCAHPS survey, SCIP, and mortality. Final rule with comment period and final rule. Federal register 2006;71:67959–8401.
Ware J Jr, Kosinski M, Keller SD. A 12-item short-form health survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34:220–33.
Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The edmonton symptom assessment system (ESAS): a simple method for the assessment of palliative care patients. J Palliat Care. 1991;7:6–9.
Wong MD, Sarkisian CA, Davis C, Kinsler J, Cunningham WE. The association between life chaos, health care use, and health status among HIV-infected persons. J Gen Intern Med. 2007;22:1286–91.
Rafferty JP, Lemkau JP, Purdy RR, Rudisill JR. Validity of the Maslach burnout inventory for family practice physicians. J Clin Psychol. 1986;42:488–92.
Berkman LF, Blumenthal J, Burg M, et al. Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) randomized Trial. JAMA. 2003;289:3106–16.
Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. Fam Med. 2004;36:588–94.
Hager ER, Quigg AM, Black MM, et al. Development and validity of a 2-item screen to identify families at risk for food insecurity. Pediatrics. 2010;126:e26–32.
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606–13.
de Jager CA, Budge MM, Clarke R. Utility of TICS-M for the assessment of cognitive function in older adults. Int J Geriatr Psychiatry. 2003;18:318–24.
Maisto SA, Carey MP, Carey KB, Gordon CM, Gleason JR. Use of the AUDIT and the DAST-10 to identify alcohol and drug use disorders among adults with a severe and persistent mental illness. Psychol Assess. 2000;12:186–92.
Maindal HT, Sandbaek A, Kirkevold M, Lauritzen T. Effect on motivation, perceived competence, and activation after participation in the “Ready to Act” programme for people with screen-detected dysglycaemia: a 1-year randomised controlled trial, Addition-DK. Scand J Pub Health. 2011;39:262–71.
Ryan AM, Burgess JF Jr, Dimick JB. Why we should not be indifferent to specification choices for difference-in-differences. Health Serv Res. 2015;50:1211–35.
Stetler CB, Legro MW, Wallace CM, et al. The role of formative evaluation in implementation research and the QUERI experience. J Gen Intern Med. 2006;21(Suppl 2):S1–8.
Gawande A. The Hot Spotters. New Yorker. January 2011. http://www.newyorker.com/magazine/2011/01/24/the-hot-spotters. Accessed 1 July 2017.
Komro KA, Flay BR, Biglan A, Wagenaar AC. Research design issues for evaluating complex multicomponent interventions in neighborhoods and communities. Transl Behav Med. 2016;6:153–9.
Barnett AG, van der Pols JC, Dobson AJ. Regression to the mean: what it is and how to deal with it. Int J Epidemiol. 2005;34:215–20.
Johnson TL, Rinehart DJ, Durfee J, et al. For many patients who use large amounts of health care services, the need is intense yet temporary. Health Aff. 2015;34:1312–9.
Ekdahl AW, Alwin J, Eckerblad J, et al. Long-term evaluation of the ambulatory geriatric assessment: a frailty intervention trial (AGe-FIT): clinical outcomes and total costs after 36 months. J Am Med Dir Assoc. 2016;17:263–8.
Meret-Hanke LA. Effects of the program of all-inclusive care for the elderly on hospital use. Gerontol. 2011;51:774–85.
Chan AW, Tetzlaff JM, Altman DG, et al. SPIRIT 2013 Statement: defining standard protocol items for clinical trials. Rev Panam Salud Publica. 2015;38:506–14.
Roccaforte WH, Burke WJ, Bayer BL, Wengel SP. Validation of a telephone version of the mini-mental state examination. J Am Geriatr Soc. 1992;40:697–702.
Weidmer BA, Brach C, Slaughter ME, Hays RD. Development of items to assess patients’ health literacy experiences at hospitals for the consumer assessment of healthcare providers and systems (CAHPS) hospital survey. Med Care. 2012;50:S12–21.