References


The following references used in developing each content for the Blueprint for Excellence and were current at the time of each module’s original release. More recent references, policies or guidelines may be available and can be found through Pubmed or a Google search. To access articles, enter the author list or publication title into Pubmed or Google. Note that some source links may have changed. Use these links to find references on specific topics. 

Appointment Scheduling For Follow up
Beliefs and Spirituality
COPD
Depression Screening
Dyspnea
Falls
Frontloading
Functional Status and Cognitive Change – Impact on Readmission
Heart Failure
Home-based Care – Agency Characteristics
Home Visits - Nurse Practitioner and Physician?
Hospice Crisis Management
Hospice Symptom Management
Hospice Treatment Preferences
Joint Replacement Complications
Joint Replacement Fast Track
Medication Reconciliation and Supporting Documentation
Pain
Patient and Caregiver Engagement
Pressure Ulcers
Readmissions / Transitions of Care Review Articles
Readmission Risk Factors
Rehabilitation
Risk Assessment
Social Work / Community Interventions – impact on readmissions
Telemonitoring
Transitions of Care – Interventions
 
Medication Reconciliation
  • Baur, C. (2010). National Action Plan to Improve Health Literacy. US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. 
  • Budnitz, D. S., Lovegrove, M. C., Shehab, N., & Richards, C. L. (2011). Emergency hospitalizations for adverse drug events in older Americans. New England journal of medicine, 365(21), 2002-2012.
  • Coleman, E. A., Smith, J. D., Raha, D., & Min, S. J. (2005). Posthospital medication discrepancies: prevalence and contributing factors. Archives of Internal Medicine, 165(16), 1842.
  • Desai, A., & Lee, M. (2007). Gibaldi's Drug Delivery Systems in pharmaceutical care. Chapter, 7, 95-100.
  • Gleason, K. M., Brake, H., Agramonte, V., & Perfetti, C. Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation. Prepared by the Island Peer Review Organization, Inc., under Contract No. HHSA2902009000 C, 13.
  • Institute for Healthcare Improvement (IHI). (2011). How-to Guide: Prevent   Adverse Drug Events by Implementing Medication Reconciliation. Cambridge, MA. (Available at www.ihi.org)
  • Joint Commission Resources and the American Society of Health-System Pharmacists (2006). Medication Reconciliation Handbook: Chapter 5: Educating your staff. Oakbrook Torrance, IL: Joint Commission Resources.
  • Morisky, D. E., Ang, A., Krousel?Wood, M., & Ward, H. J. (2008). Predictive validity of a medication adherence measure in an outpatient setting. The Journal of Clinical Hypertension, 10(5), 348-354.
  • Pronovost, P., Weast, B., et al. (2003). Medication reconciliation: a practical tool to reduce the risk of medication errors. Journal of critical care, 18(4), 201.
Frontloading
  • Budnitz, D. S., Lovegrove, M. C., Shehab, N., & Richards, C. L. (2011). Emergency hospitalizations for adverse drug events in older Americans. New England journal of medicine, 365(21), 2002 - 2012. 
  • Crossen-Sills, J., Toomey, I., & Doherty, M. (2006). Strategies to reduce unplanned hospitalizations of home healthcare patients: a step-by-step approach. Home Healthcare Nurse, 24(6), 369-376.
  • Fazzi, R., Agoglia, R., Mazza, G., & Glading-DiLorenzo, J. (2006). The Briggs National Quality Improvement/Hospitalization Reduction Study. Caring: National Association for Home Care magazine, 25(2), 70. 
  • Jencks, S. F., Williams, M. V., & Coleman, E. A. (2009). Rehospitalizations among patients in the Medicare fee-for-service program. New England Journal of Medicine, 360(14), 1418-1428.
  • Rogers, J., Perlic, M., & Madigan, E. A. (2007). The effect of frontloading visits on patient outcomes. Home Healthcare Nurse, 25(2), 103-109.
  • Rogers, J. & Schott, D. (2008). Front loading visits: A Best practice measure to decrease rehospitalization in heart failure patients. Home Health Care Management Practice, 20(2), 147-153. doi:10.1177/1084822307306765
  • Sevin, C., Evdokimoff, M., Sobolewski, S., Taylor, J., Rutherford, P. & Coleman, E. (2011). How-to Guide: Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations. Retrieved from http://www.ihi.org/knowledge/Pages/Tools/HowtoGuideImprovingTransitionsfromHospitaltoHomeHealthCareReduceAvoidableHospitalizations.aspx
  • The Delta Study to Reduce Hospitalizations: A National Study to Reduce Avoidable Hospitalizations through Home Care January 2012.  www.deltahealthtech.com/research/projects/hospitalizations/
Appointment Scheduling
  • Göhler, A., Januzzi, J. L., Worrell, S. S., Osterziel, K. J., Scott Gazelle, G., Dietz, R., & Siebert, U. (2006). A systematic meta-analysis of the efficacy and heterogeneity of disease management programs in congestive heart failure. Journal of cardiac failure, 12(7), 554-567.
  • Hernandez, A. F., Greiner, M. A., Fonarow, G. C., Hammill, B. G., Heidenreich, P. A., Yancy, C. W., ... & Curtis, L. H. (2010). Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA: The Journal of the American Medical Association, 303(17), 1716-1722.
  • Jencks, S. F., Williams, M. V., & Coleman, E. A. (2009). Rehospitalizations among patients in the Medicare fee-for-service program. New England Journal of Medicine, 360(14), 1418-1428.
  • Misky, G. J., Wald, H. L., & Coleman, E. A. (2010). Post?hospitalization transitions: Examining the effects of timing of primary care provider follow?up. Journal of Hospital Medicine, 5(7), 392-397.
  • Weinberger, M., Oddone, E. Z., & Henderson, W. G. (1996). Does increased access to primary care reduce hospital readmissions?. New England Journal of Medicine, 334(22), 1441-1447.
Critical Interventions in the First and Second Visits
  • Baker, D. W., Gazmararian, J. A., Williams, M. V., Scott, T., Parker, R. M., Green, D., ... & Peel, J. (2002). Functional health literacy and the risk of hospital admission among Medicare managed care enrollees. Journal Information, 92(8).
  • Brach, C., Dreyer, B., Schyve, P., Hernandez, L. M., Baur, C., Lemerise, A. J., & Parker, R. (2012). Attributes of a health literate organization.
  • Briggs, (2006). Briggs National Quality Improvement/Hospitalization Reduction Study. [Web site]. Retrieved from http://www.fazzi.com/briggs-national-quality-improvement-hospitalization-reduction-study.html
  • Calys, M., Gagnon, K., Jernigan, S. (2012). A Validation Study of the Missouri Alliance for Home Care Fall Risk Assessment Tool. Home Health Care Management & Practice. Vol. 25 no. 2 39-44. doi: 10.1177/1084822312457942
  • 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.
  • Collopy, B., Dubler, N., & Zuckeman, C. (1990). The ethics of home care: Autonomy and accommodation. Hastings Center Report, 20(2), 1-16.
  • Davis, T. C., Jackson, R. H., Bocchini, J. A., Arnold, C., Mayeaux, E. J., & Frederickson, D. (1994). Comprehension is greater using a short vaccine information pamphlet with graphics and simple language. J Gen Intern Med, 9(suppl 2), 103.
  • DeWalt, D. A., Callahan, L. F., Hawk, V. H., Broucksou, K., Hink, A., & Rudd, R. (2010). Health Literacy Universal Precautions Toolkit. (Prepared by North Carolina Network Consortium, The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, under Contract No. HHSA290200710014. AHRQ Publication No. 10-0046-EF). Rockville, MD: Agency for Healthcare Research and Quality 2010. Rockville, MD: Agency for Healthcare Research and Quality.
  • Empowerment and engagement among low-income Californians: Enhancing patient-centered care. (2012, September). 2012 Blue Shield of California Foundation Survey.
  • Evdokimoff, M. (2011). One Home Health Agency's Quality Improvement Project to Decrease Rehospitalizations: Utilizing a Transitions Model. Home Healthcare Nurse, 29(3), 180-193.
  • Floyd, R. L., Sobell, M., Velasquez, M. M., Ingersoll, K., Nettleman, M., Sobell, L., ... & Nagaraja, J. (2007). Preventing alcohol-exposed pregnancies: a randomized controlled trial. American journal of preventive medicine, 32(1), 1.
  • Greenberg, E., Dunleavy, E., Kutner, M., & White, S. (2007). Literacy behind bars: Results from the 2003 national assessment of adult literacy prison survey.
  • Jencks, S. F., Williams, M. V., & Coleman, E. A. (2009). Rehospitalizations among patients in the Medicare fee-for-service program. New England Journal of Medicine, 360(14), 1418-1428.
  • Hansen, L. O., Young, R. S., Hinami, K., Leung, A., & Williams, M. V. (2011). Interventions to reduce 30-day rehospitalization: a systematic review. Annals of internal medicine, 155(8), 520-528.
  • He, W., Sengupta, M., Velkoff, V. A., & DeBarros, K. A. (2005). 65+ in the United States: 2005. US Census Bureau. Current Population Reports P23-209. Washington, DC: US Government Printing Office.
  • Knickman, J. R., & Snell, E. K. (2002). The 2030 problem: caring for aging baby boomers. Health services research, 37(4), 849-884.
  • Hennessey, B., & Suter, P. (2011). The Community-Based Transitions Model: One Agency's Experience. Home Healthcare Nurse, 29(4), 218.
  • Huffman, M. (2007). Health coaching: a new and exciting technique to enhance patient self-management and improve outcomes. Home Healthcare Nurse, 25(4), 271-274.
  • Institute of Medicine (US). Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. National Academies Press.
  • Kotter, J. P., & Cohen, D. S. (2002). The heart of change: Real-life stories of how people change their organizations. Harvard Business Press.
  • Madigan, E., Schott, D. & Matthews, C. (2001). Rehospitalization among Home Healthcare Patients: Results of a Prospective Study. Home Healthcare Nurse, 19(5), 298-305. doi:10.1097/00004045-200105000-00012
  • Murtaugh, C., Peng, T., Totten, A., Costello, B., Moore, S., & Aykan, H. (2009). Complexity in geriatric home healthcare. Journal for Healthcare Quality, 31(2), 34-43. National Patient Safety Foundation. (2011). Ask Me 3. Boston, MA.
  • Nielsen-Bohlman, L., Panzer, A. M., & Kindig, D. A. (Eds.). (2004). Health literacy: A prescription to end confusion. National Academies Press.
  • Parker, R., & Ratzan, S. C. (2010). Health literacy: A second decade of distinction for Americans. Journal of health communication, 15(S2), 20-33.
  • Parry, C., Min, S., Chugh, A., Chalmers, S. & Coleman, E. (2009). Further Application of the Care Transitions Intervention: Results of a Randomized Controlled Trial Conducted in a Fee-for-Service Setting. Home Care Services Quarterly, 28(2-3), 84-99.
  • Parry, C., Min, S. J., Chugh, A., Chalmers, S., & Coleman, E. A. (2009). Further application of the care transitions intervention: results of a randomized controlled trial conducted in a fee-for-service setting. Home Health Care Services Quarterly, 28(2-3), 84-99.
  • Partnering with Patients and Families to Design a Patient and Family Centered Health Care System. Institute for Family-Centered Care in Collaboration with  IHI, April 2008.
  • Peterson, P. N., Shetterly, S. M., Clarke, C. L., Bekelman, D. B., Chan, P. S., Allen, L. A., ... & Masoudi, F. A. (2011). Health literacy and outcomes among patients with heart failure. JAMA: The Journal of the American Medical Association, 305(16), 1695-1701.
  • Rogers, J., Perlic, M., & Madigan, E. A. (2007). The effect of frontloading visits on patient outcomes. Home Healthcare Nurse, 25(2), 103-109.
  • Rollnick S, Mason P, Butler C. Health Behavior Change – A Guide for Practitioners. New York: The Churchill Livingston, 1999
  • Rollnick, S., Mason, P., & Butler, C. (1999). Health behavior change: a guide for practitioners. Edinburgh and New York.
  • Rubak, S., Sandbæk, A., Lauritzen, T., & Christensen, B. (2005). Motivational interviewing: a systematic review and meta-analysis. The British journal of general practice, 55(513), 305.
  • Rudd, R. E., Anderson, J. E., Oppenheimer, S., & Nath, C. (2007). Health literacy: An update of public health and medical literature. Review of adult learning and literacy, 7, 175-204.
  • Schwartzberg, J. G., Jonathan. VanGeest, & Claire. Wang. (2005). Understanding health literacy. Chicago, IL: AMA press.
  • Sevin, C., Evdokimoff, M., Sobolewski, S., Taylor, J., Rutherford, P. & Coleman, E. (2011). How-to Guide: Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations. Retrieved from http://www.ihi.org/knowledge/Pages/Tools/HowtoGuideImprovingTransitionsfromHospitaltoHomeHealthCareReduceAvoidableHospitalizations.aspx
  • Salvin, S., Galanti, G., Kuo, A. The 4 C’s of Culture: A Mnemonic for Health Care Professionals. Retrieved from http://www.gagalanti.org/articles/The4CsofCulture.pdf.
  • Wynia, M. K., Von Kohorn, I., & Mitchell, P. H. (2012). Challenges at the Intersection of Team-Based and Patient-Centered Health CareInsights From an IOM Working GroupTeam-Based and Patient-Centered Health Care. JAMA: The Journal of the American Medical Association, 308(13), 1327-1328.
Risk Assessment (see also readmission)
  • Boult, C., Dowd, B., McCaffrey, D., Boult, L., Hernandez, R., & Krulewitch, H. (1993). Screening elders for risk of hospital admission. Journal of the American Geriatrics Society, 41(8), 811.
  • Gruneir, A., Dhalla, I. A., van Walraven, C., Fischer, H. D., Camacho, X., Rochon, P. A., & Anderson, G. M. (2011). Unplanned readmissions after hospital discharge among patients identified as being at high risk for readmission using a validated predictive algorithm. Open Medicine, 5(2), e104.
  • Jack, B. W., Chetty, V. K., Anthony, D., Greenwald, J. L., Sanchez, G. M., Johnson, A. E., ... & Culpepper, L. (2009). A Reengineered Hospital Discharge Program to Decrease Rehospitalization A Randomized Trial. Annals of Internal Medicine, 150(3), 178-187.        
  • Lemke, K. W., Weiner, J. P., & Clark, J. M. (2012). Development and validation of a model for predicting inpatient hospitalization. Medical Care, 50(2), 131-139.
  • Meldon, S. W., Mion, L. C., Palmer, R. M., Drew, B. L., Connor, J. T., Lewicki, L. J., ... & Emerman, C. L. (2003). A Brief Risk stratification Tool to Predict Repeat Emergency Department Visits and Hospitalizationsin Older Patients Discharged from the Emergency Department. Academic Emergency Medicine, 10(3), 224-232.
  • Miller, W. R., & Rollnick, S. (2002). Motivational Interviewing: Preparing people for change Guilford. New York. 
  • Rosati, R. J., & Huang, L. (2007). Development and testing of an analytic model to identify home healthcare patients at risk for a hospitalization within the first 60 days of care. Home Health Care Services Quarterly, 26(4), 21-36.
  • Sevin, C., Evdokimoff, M., Sobolewski, S., Taylor, J., Rutherford, P. & Coleman, E. (2011). How-to Guide: Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations. Retrieved from http://www.ihi.org/knowledge/Pages/Tools/HowtoGuideImprovingTransitionsfromHospitaltoHomeHealthCareReduceAvoidableHospitalizations.aspx
  • Society for Hospital Medicine. The 8Ps: Assessing Your Patient’s Risk For Adverse Events After Discharge. Accessed 2013 at http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/PDFs/TARGET.pdf
  • Soeken, K. L., Prescott, P. A., Herron, D. G., & Creasia, J. (1991). Predictors of Hospital Readmission A Meta-Analysis. Evaluation & the Health Professions, 14(3), 262-281.
Falls Risk Assessment
  • Boushon, B. (2008). Transforming Care at the Bedside: How-to Guide: Reducing Patient Injuries from Falls. Institute for Healthcare Improvement.
  • Bright, L. (2005). Strategies to improve the patient safety outcome indicator: preventing or reducing falls. Home Healthcare Nurse, 23(1), 29-36.        
  • Ellenbecker, C. H., Samia, L., Cushman, M. J., & Alster, K. (2008). . Patient Safety and Quality in Home Health Care. Patient safety and quality: an evidence-based handbook for nurses, 1.          
  • Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. (2012)
  • Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012 Sep 12;(9):CD007146
  • Gillespie, L. D., Gillespie, W. J., Robertson, M. C., Lamb, S. E., Cumming, R. G., & Rowe, B. H. (2003). Interventions for preventing falls in elderly people (Cochrane Review). The Cochrane Library, 4(3).
  • Hogan, D. B., MacDonald, F. A., Betts, J., Bricker, S., Ebly, E. M., Delarue, B., ... & Metcalf, B. (2001). A randomized controlled trial of a community-based consultation service to prevent falls. Canadian Medical Association Journal, 165(5), 537-543.        
  • Isberner, F., Ritzel, D., Sarvela, P., Brown, K., Hu, P., & Newbolds, D. (1998). Falls of elderly rural home health clients. Home health care services quarterly, 17(2), 41-51.
  • Lewis, C. L., Moutoux, M., Slaughter, M., & Bailey, S. P. (2004). Characteristics of individuals who fell while receiving home health services. Physical therapy, 84(1), 23-32.
  • Stevens, J. A., Corso, P. S., Finkelstein, E. A., & Miller, T. R. (2006). The costs of fatal and non-fatal falls among older adults. Injury prevention, 12(5), 290-295.
  • Sheeran, T., Brown, E. L., Nassisi, P., & Bruce, M. L. (2004). Does depression predict falls among home health patients? Using a clinical-research partnership to improve the quality of geriatric care. Home healthcare nurse, 22(6), 384-389.
  • Sperling, S., Neal, K., Hales, K., Adams, D., & Frey, D. (2005). A quality improvement project to reduce falls and improve medication management. Home health care services quarterly, 24(1-2), 13-28.
  • Stevens, J. A. (2005). Falls among older adults—risk factors and prevention strategies. Journal of Safety Research, 36(4), 409-411.
  • Tinetti, M. E., Baker, D. I., McAvay, G., Claus, E. B., Garrett, P., Gottschalk, M., ... & Horwitz, R. I. (1994). A multifactorial intervention to reduce the risk of falling among elderly people living in the community. New England Journal of Medicine, 331(13), 821-827.
  • Tinetti, M. E., Baker, D. I., King, M., Gottschalk, M., Murphy, T. E., Acampora, D., ... & Allore, H. G. (2008). Effect of dissemination of evidence in reducing injuries from falls. New England Journal of Medicine, 359(3), 252-261.
  • Yuan, J. R., & Kelly, J. (2006). Falls prevention, or 'I think I can, I think I can": An ensemble approach to falls management. Home healthcare nurse, 24(2), 103-111
Depression Screening 
  • Bruce, Martha L. PhD, MPH; Sheeran, Thomas PhD, ME; Raue, Patrick J. PhD; Reilly, Catherine F. MPH; Greenberg, Rebecca L. MS; Pomerantz, Judith C. RN, MS, PMHCNS-BC; Meyers, Barnett S. MD; Weinberger, Mark I. PhD, MPH; Johnston, Christine L. MPH. (2011). Depression Care for Patients at Home (Depression CAREPATH): Intervention Development and Implementation, Part 1. Home Healthcare Nurse. Volume 29 - Issue 7 - p 416–426.
  • Bruce, Martha L. PhD, MPH; Raue, Patrick J. PhD; Sheeran, Thomas PhD, ME; Reilly, Catherine MPH; Pomerantz, Judith C. RN, MS, PMHCNS-BC; Meyers, Barnett S. MD; Weinberger, Mark I. PhD, MPH; Zukowski, Diane RN, BSN. (2011). Depression Care for Patients at Home (Depression CAREPATH): Home Care Depression Care Management Protocol, Part 2. Home Healthcare Nurse. Volume 29 - Issue 8 - p 480–489.  
  • Bruce, M. L. (2002). Psychosocial risk factors for depressive disorders in late life. Biological Psychiatry, 52(3), 175.
  • Byers, A. L., Sheeran, T., Mlodzianowski, A. E., Meyers, B. S., Nassisi, P., & Bruce, M. L. (2008). Depression and risk for adverse falls in older home health care patients. Research in gerontological nursing, 1(4), 245.
  • Brown, E. L., Raue, P. J., Roos, B. A., Sheeran, T., & Bruce, M. L. (2010). Training nursing staff to recognize depression in home healthcare. Journal of the American Geriatrics Society, 58(1), 122-128.
  • Cog, A. M., Cog, A. M., & Ouderen, P. (2000). Borson S, Scanlan J, Brush M, et al. (2000) The Mini-Cog: a cognitive ‘vital signs’ measure for dementia screening in multi-lingual elderly. Int. J. Geriatr. Psychiatry, 15(11), 1021-27.
  • Gellis, Z. D., & Kang-Yi, C. (2012). Meta-Analysis of the Effect of Cardiac Rehabilitation Interventions on Depression Outcomes in Adults 64 Years of Age and Older. The American journal of cardiology.
  • John D. and Catherine T. MacArthur Foundation. (2009). Depression Management Tool Kit. Retrieved from http://www.depression-primarycare.org/clinicians/toolkits/full/
  • Madden-Baer, R., McConnell, E., Rosati, R. J., Rosenfeld, P., & Edison, I. (2013). Implementation and Evaluation of a Depression Care Model for Homebound Elderly. Journal of Nursing Care Quality, 28(1), 33-42.
  • US Preventive Services Task Force (2009). Screening for depression in adults: US Preventive Services Task Force recommendation statement. Annals of internal medicine, 151(11), 784-792.
  • Raue, P. J., Meyers, B. S., McAvay, G. J., Brown, E. L., Keohane, D., & Bruce, M. L. (2003). One-month stability of depression among elderly home-care patients. The American journal of geriatric psychiatry, 11(5), 543-550.
  • Sheeran, T., Byers, A. L., & Bruce, M. L. (2010). Depression and increased short-term hospitalization risk among geriatric patients receiving home health care services. Psychiatric services (Washington, DC), 61(1), 78.
  • Valente, S. M. (2005). Detecting and evaluating depression among elderly patients in home health. Home Health Care Management & Practice, 17(2), 101-108.
Rehabilitation
  • Clarkson HM. Joint Motion and Function Assessment: A Research-Based Practical Guide. Philadelphia, PA: Lippincott Williams & Watkins; 2005.
  • den Hertog A1, Gliesche K, Timm J, Mühlbauer B, Zebrowski S. (2012) Pathway-controlled fast-track rehabilitation after total knee arthroplasty: a randomized prospective clinical study evaluating the recovery pattern, drug consumption, and length of stay. Arch Orthop Trauma Surg. 2012 Aug;132(8):1153-63.
  • Fisher SR, Graham JE, Krishnan S, Ottenbacher KJ. (2015) Predictors of 30-Day Readmission Following Inpatient Rehabilitation for Patients at High Risk. Phys Ther. 2015 Sep 10.
  • Health Quality Ontario. (2005) Physiotherapy rehabilitation after total knee or hip replacement: an evidence-based analysis. Ont Health Technol Assess Ser. 2005;5(8):1-91.
  • Quack V, Ippendorf AV, Betsch M, Schenker H, Nebelung S,  Rath B, Tingart M, Lüring C. (2015)  in German.  [Multidisciplinary Rehabilitation and Fast-track Rehabilitation after Knee Replacement: Faster, Better, Cheaper? A Survey and Systematic Review of Literature]. Rehabilitation (Stuttg). 2015 Aug;54(4):245-51.
  • Westby MD1, Brittain A, Backman CL. (2014) Expert consensus on best practices for post-acute rehabilitation after total hip and knee arthroplasty: a Canada and United States Delphi study. Arthritis Care Res (Hoboken). 2014 Mar;66(3):411-23.
Joint Replacement Complications
  • Autar, R. (2011) Evidence based venous thromboprophylaxis in patients undergoing total hip replacement (THR), total knee replacement (TKR) and hip fracture surgery (HFS). International Journal of Orthopaedic and Trauma Nursing. Volume 15, Issue 3, August 2011, Pages 145–154.
  • Dumville JC, Gray TA, Walter CJ, Sharp CA, Page T.  (2014) Dressings for the prevention of surgical site infection. Cochrane Database Syst Rev. 2014 Sep 1;9.
  • Kapadia BH, Berg RA, Daley JA, Fritz J, Bhave A, Mont MA. (2015) Periprosthetic joint infection. Lancet. 2015 Jun 26. pii: S0140-6736(14)61798-0.
  • Keeney JA, Nam D, Johnson SR, Nunley RM, Clohisy JC, Barrack RL.  (2015) The Impact of Risk Reduction Initiatives on Readmission: THA and TKA Readmission Rates. J Arthroplasty. 2015 Jun 12. pii: S0883-5403(15)00517-3.
  • Lamagni T. (2014) Epidemiology and burden of prosthetic joint infections. J Antimicrob Chemother. 2014 Sep;69 Suppl 1:i5-10.
  • Papavasiliou AV, Bardakos NV. (2012) Complications of arthroscopic surgery of the hip. Bone Joint Res. 2012 Jul 1;1(7):131-44.
  • Shih SL, Gerrard P, Goldstein R, Mix J, Ryan CM, Niewczyk P, Kazis L, Hefner J, Ackerly DC, Zafonte R, Schneider JC.  (2015) Functional Status Outperforms Comorbidities in Predicting Acute Care Readmissions in Medically Complex Patients. J Gen Intern Med. 2015 May 9. [Epub ahead of print]. 
Joint Replacement Fast Track Programs
  • Aasvang EK, Luna IE, Kehlet H. (2015) Challenges in postdischarge function and recovery: the case of fast-track hip and knee arthroplasty. Br J Anaesth. 2015 Jul 25. pii: aev257. [Epub ahead of print]
  • Gulotta LV, Padgett DE, Sculco TP, Urban M, Lyman S, Nestor BJ. (2011) Fast Track THR: One Hospital's Experience with a 2-Day Length of Stay Protocol for Total Hip Replacement. HSS J. 2011 Oct;7(3):223-8.
  • Husted H. (2012) Fast-track hip and knee arthroplasty: clinical and organizational aspects. Acta Orthop Suppl. 2012 Oct;83(346):1-39.
  • Kehlet H, Thienpont E. (2013) Fast-track knee arthroplasty -- status and future challenges. Knee. 2013 Sep;20 Suppl 1:S29-33.
  • Lloyd JM, Wainwright T, Middleton RG. What is the role of minimally invasive surgery in a fast track hip and knee replacement pathway? Ann R Coll Surg Engl. 2012 Apr;94(3):148-51.
  • Pereira F, Pollard F, Koen R, Wood GC. (2015). Reducing hospital length of stay following total hip and knee replacement surgery with a dedicated fast track program.  Current Orthopaedic Practice Volume 26  Number 1 January/February 2015.
  • Raphael M, Jaeger M, van Vlymen J. (2011) Easily adoptable total joint arthroplasty program allows discharge home in two days. Can J Anaesth. 2011 Oct;58(10):902-10.
  • Specht K, Kjaersgaard-Andersen P, Kehlet H, Wedderkopp N, Pedersen BD. (2015) High patient satisfaction in 445 patients who underwent fast-track hip or knee replacement. Acta Orthop. 2015 Jun 24:1-6.
Readmissions / Transitions of Care Review Articles
  • Totten AM, White-Chu EF, Wasson N, Morgan E, Kansagara D, Davis-O'Reilly C, Goodlin S. Editors Home-Based Primary Care Interventions. Rockville (MD): Agency for Healthcare Research and Quality (US); 2016 Feb. Report No.: 15(16)-EHC036-EF. AHRQ Comparative Effectiveness Reviews.
  • Zimmerman LWilson FA et.al.  Cost-Effectiveness of a Care Transition Intervention Among Multimorbid Patients. West J Nurs Res. 2016 Oct 1:193945916673834.
  • Feltner C, Jones CD, Cené CW, Zheng ZJ, et.al. Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis.  Ann Intern Med. 2014 Jun 3;160(11):774-84.
  • Kansagara D, Chiovaro JC, Kagen D, Jencks S et.al So many options, where do we start? An overview of the care transitions literature. J Hosp Med. 2016 Mar;11(3):221-30.
  • Kansagara D, Chiovaro JC, Kagen D, Jencks S, et. al. Transitions of Care from Hospital to Home: An Overview of Systematic Reviews and Recommendations for Improving Transitional Care in the Veterans Health Administration
  • Aaron L. Leppin, MD; Michael R. Gionfriddo, PharmD; Maya Kessler, MD; et.al. Preventing 30-Day Hospital Readmissions A Systematic Review and Meta-analysis of Randomized Trials JAMA Intern Med. 2014;174(7):1095-1107. PMID: 24820131
  • Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med. 2011 Oct 18;155(8):520-8. 
  • Linertová RGarcía-Pérez LVázquez-Díaz JRLorenzo-Riera ASarría-Santamera A. Interventions to reduce hospital readmissions in the elderly: in-hospital or home care. A systematic review. J Eval Clin Pract. 2011 Dec;17(6):1167-75.
  • Readmission Risk Factors
  • Nguyen OKMakam AN, et.al. Vital Signs Are Still Vital: Instability on Discharge and the Risk of Post-Discharge Adverse Outcomes. J Gen Intern Med. 2017 Jan;32(1):42-48.
  • Burke RE, Whitfield EA, Hittle D, Min SJ, et.a. Hospital Readmission From Post-Acute Care Facilities: Risk Factors, Timing, and Outcomes. J Am Med Dir Assoc. 2016 Mar 1;17(3):249-55.PMID: 26715357
  • Meddings JReichert H, et.al. The Impact of Disability and Social Determinants of Health on Condition-Specific Readmissions beyond Medicare Risk Adjustments: A Cohort Study. J Gen Intern Med. 2017 Jan;32(1):71-80.
  • Fortinsky RHMadigan EASheehan TJTullai-McGuinness SKleppinger A. Risk factors for hospitalization in a national sample of Medicare home health care patients.  J Appl Gerontol. 2014 Jun;33(4):474-93.
  • Fisher SR, Graham JE, Krishnan S, Ottenbacher KJ. Predictors of 30-Day Readmission Following Inpatient Rehabilitation for Patients at High Risk for Hospital Readmission. Phys Ther. 2016 Jan;96(1):62-70. 
  • Olson CHDey SKumar V, Monsen KAWestra BL. Clustering of elderly patient subgroups to identify medication-related readmission risks. Int J Med Inform. 2016 Jan;85(1):43-52.
  • Burke RE, Whitfield EA, Hittle D, Min SJ, Levy C, Prochazka AV, Coleman EA, Schwartz R, Ginde AA. Hospital Readmission From Post-Acute Care Facilities: Risk Factors, Timing, and Outcomes. J Am Med Dir Assoc. 2016 Mar 1;17(3):249-55.
  • Jiang HJ, Boutwell AE, Maxwell J, Bourgoin A, Regenstein M, Andres E. Understanding Patient, Provider, and System Factors Related to Medicaid Readmissions. Jt Comm J Qual Patient Saf. 2016 Mar;42(3):115-21
  • Jones TK, Fuchs BD, Small DS, et. al. Post-Acute Care Use and Hospital Readmission after Sepsis. Ann Am Thorac Soc. 2015 Jun;12(6):904-13.
Patient / Caregiver Engagement
  • Ahmad FS, Barg FK, Bowles KH, et.al. Comparing Perspectives of Patients, Caregivers, and Clinicians on Heart Failure Management. J Card Fail. 2016 Mar;22(3):210-7.
  • Naylor MD, Hirschman KB, O'Connor M, Barg R, Pauly MV. Engaging older adults in their transitional care: what more needs to be done? J Comp Eff Res. 2013 Sep;2(5):457-68.
  • Riegel B, Masterson Creber R, Hill J, Chittams J, Hoke L. Effectiveness of Motivational Interviewing in Decreasing Hospital Readmission in Adults With Heart Failure and Multimorbidity. Clin Nurs Res. 2016 Jan 6. 
Care Transitions – Specific Interventions And Needs
  • Coleman EA, Roman SP. Family caregivers' experiences during transitions out of hospital. J Healthc Qual. 2015 Jan-Feb;37(1):12-21. 
  • Morrison JPalumbo MVRambur B. Reducing Preventable Hospitalizations With Two Models of Transitional Care. J Nurs Scholarsh. 2016 May;48(3):322-9.
  • Coleman EAParry CChalmers SMin SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006 Sep 25;166(17):1822-8.
  • Kangovi S, Grande D, Meehan P, Mitra N, Shannon R, Long JA. Perceptions of readmitted patients on the transition from hospital to home. J Hosp Med. 2012 Nov-Dec;7(9):709-12.
Nurse Practitioner And Physician Home Visits
  • Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, Schwartz JS. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999 Feb 17;281(7):613-20.
  • Moore JA. Evaluation of the efficacy of a nurse practitioner-led home-based congestive heart failure clinical pathway. Home Health Care Serv Q. 2016 Jan-Mar;35(1):39-51. 
  • Rytter L, Jakobsen HN, Rønholt F, Hammer AV, Andreasen AH, Nissen A, Kjellberg J. Comprehensive discharge follow-up in patients' homes by GPs and district nurses of elderly patients. A randomized controlled trial. Scand J Prim Health Care. 2010 Sep;28(3):146-53.
  • Nabagiez JP, Shariff MA, Molloy WJ, Demissie S, McGinn JT Jr. Cost Analysis of Physician Assistant Home Visit Program to Reduce Readmissions After Cardiac Surgery. Ann Thorac Surg. 2016 May 24
  • Condon C, Lycan S, Duncan P, Bushnell C. Reducing Readmissions After Stroke With a Structured Nurse Practitioner/Registered Nurse Transitional Stroke Program. Stroke. 2016 Jun;47(6):1599-604.
  • Thygesen LC, Fokdal S, Gjørup T, Taylor RS, Zwisler AD; Prevention of Early Readmission Research Group. Can municipality-based post-discharge follow-up visits including a general practitioner reduce early readmission among the fragile elderly (65+ years old)? A randomized controlled trial. Scand J Prim Health Care. 2015 Jun;33(2):65-73.
  • Stewart S, Wiley JF, Ball J, Chan YK, Ahamed Y, Thompson DR, Carrington MJ. Impact of Nurse-Led, Multidisciplinary Home-Based Intervention on Event-Free Survival Across the Spectrum of Chronic Heart Disease: Composite Analysis of Health Outcomes in 1226 Patients From 3 Randomized Trials. Circulation. 2016 May 10;133(19):1867-77
  • Jackson C, Kasper EW, Williams C, DuBard CA. Incremental Benefit of a Home Visit Following Discharge for Patients with Multiple Chronic Conditions Receiving Transitional Care. Popul Health Manag. 2016 Jun;19(3):163-70.
  • Field TS, Ogarek J, Garber L, Reed G, Gurwitz JH. Association of early post-discharge follow-up by a primary care physician and 30-day rehospitalization among older adults. J Gen Intern Med. 2015 May;30(5):565-71.
Telemonitoring And Misc Interventions To Prevent Readmissions (see also review articles)
  • Ong MK, Romano PS, Edgington S, Better Effectiveness After Transition–Heart Failure (BEAT-HF) Research Group et. al. Effectiveness of Remote Patient Monitoring After Discharge of Hospitalized Patients With Heart Failure: The Better Effectiveness After Transition-Heart Failure (BEAT-HF) Randomized Clinical Trial. JAMA Intern Med. 2016 Mar 1;176(3):310-8
  • Blum K, Gottlieb SS. The effect of a randomized trial of home telemonitoring on medical costs, 30-day readmissions, mortality, and health-related quality of life in a cohort of community-dwelling heart failure patients. J Card Fail. 2014 Jul;20(7):513-21.
  • O'Connor MBowles KHFeldman PHSt Pierre MJarrín OShah SMurtaugh CM. Frontloading and intensity of skilled home health visits: a state of the science. Home Health Care Serv Q. 2014;33(3):159-75.
  • Press MJGerber LMPeng TRPesko MF, et.al. Postdischarge Communication Between Home Health Nurses and Physicians: Measurement, Quality, and Outcomes. J Am Geriatr Soc. 2015 Jul;63(7):1299-305.
  • Mekonnen AB, McLachlan AJ, Brien JA. Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital  transitions: a systematic review and meta-analysis. BMJ Open. 2016 Feb 23;6(2)
  • Lukas L, Foltz C, Paxton H. Hospital outcomes for a home-based palliative medicine consulting service. J Palliat Med. 2013 Feb;16(2):179-84.
  • Ventura ADBurney SBrooker JFletcher JRicciardelli L. Home-based palliative care: a systematic literature review of the self-reported unmet needs of patients and carers. Palliat Med. 2014 May;28(5):391-402. 
Social Work/Community Services To Reduce Readmissions Functional Status, Cognitive Changes And Other Factors Influencing Readmission
  • Nicholas LH, Bynum JP, Iwashyna TJ et al. Advance Directives And Nursing Home Stays Associated With Less Aggressive End-Of-Life Care For Patients With Severe Dementia. Health Aff April 2014 vol. 33 no. 4 667-674
  • Greysen SRStijacic Cenzer I, et.al. Functional impairment and hospital readmission in Medicare seniors. JAMA Intern Med. 2015 Apr;175(4):559-65.
  • Agarwal KS, Kazim R, Xu JBorson STaffet GE. Unrecognized Cognitive Impairment and Its Effect on Heart Failure Readmissions of Elderly Adults. J Am Geriatr Soc. 2016 Nov;64(11):2296-2301. doi: 10.1111/jgs.14471. Epub 2016 Sep 27.
  • Anderson REBirge SJ. Cognitive Dysfunction, Medication Management, and the Risk of Readmission in Hospital Inpatients. J Am Geriatr Soc. 2016 Jul;64(7):1464-8. doi:  
  • Ouellet MCSirois MJ, et al. Is cognitive function a concern in independent elderly adults discharged home from the emergency department in Canada after a minor injury?
  • Tonkikh O, Shadmi E, Flaks-Manov N, Hoshen M, Balicer RD,3, Zisberg A. Functional status before and during acute hospitalization and readmission risk identification. J Hosp Med. 2016 Apr 30.
  • Shih SL, Gerrard P, Goldstein R, Mix J, Ryan CM, Niewczyk P, Kazis L, Hefner J, Ackerly DC, Zafonte R, Schneider JC. Functional Status Outperforms Comorbidities in Predicting Acute Care Readmissions in Medically Complex Patients. J Gen Intern Med. 2015 Nov;30(11):1688-95.
  • Buurman BM, Parlevliet JL, et.al. Comprehensive Geriatric Assessment and Transitional Care in Acutely Hospitalized Patients: The Transitional Care Bridge Randomized Clinical Trial. JAMA Intern Med. 2016 Mar 1;176(3):302-9.
  • Odonkor CA, Hurst PV, Kondo N, Makary MA, Pronovost PJ. Beyond the Hospital Gates: Elucidating the Interactive Association of Social Support, Depressive Symptoms, and Physical Function with 30-Day Readmissions. Am J Phys Med Rehabil. 2015 Jul;94(7):555-67.
Home Based Care Agency Characteristics And Policy Issues Impacting Readmissions Hospice Crisis Management
  • Anewalt, P. (2009). Fired up or burned out? Understanding the importance of professional boundaries in home healthcare and hospice. Home Healthcare Nurse, 27, 590-597.
  • Connor, S., Casarett, D., Spence, C., Teno, J., Rhodes, R., & Shu, J. (2007). Timing of referral to hospice and quality of care: Length of stay and bereaved family members' perceptions of the timing of hospice referral. Journal of Pain and Symptom Management, 34, 120-125.
Hospice Distressing Symptom Management
  • Alexander, S. (2009). Malignant fungating wounds: Epidemiology, etiology, presentation and assessment. Journal of Wound Care, 18(7), 273-274, 276-278, 280.
  • Anderson, P.R., Bean, G.E., & Piech, M.A. (2010). Fatigue. In B.R. Ferrell & N. Coyle (Eds.), Oxford textbook of palliative nursing (3rd ed.) (pp. 187-210). Oxford, NY: Oxford University Press.
  • Breitbart, W., Rosenfeld, B., Roth, A., Smith, M.J., Cohen, K., & Passik, S. (1997). The Memorial Delirium Assessment Scale. Journal of Pain and Symptom Management, 13(3), 128-37.
  • Canadian Partnership Against Cancer and the Canadian Association of Psychosocial Oncology (CAPO). (2010). A Pan-Canadian practice guideline: Screening, assessment and care of psychosocial distress (depression, anxiety) in adults with cancer. Retrieved from http://www.capo.ca/ENGLISH_Depression_Anxiety_Guidelines_for_Posting.pdf
  • Canadian Partnership Against Cancer and the Canadian Association of Psychosocial Oncology (CAPO). (2011). A Pan-Canadian practice guideline: Screening, assessment and care of cancer-related fatigue in adults with cancer. Retrieved from
  • http://www.capo.ca/Fatigue_Guideline.pdf
  • Clary, P.L., & Lawson, P. (2009). Pharmacologic pearls for end-of-life care. American Family Physician, 79(12), 1059-1065. Retrieved from http://www.aafp.org/afp/2009/0615/p1059.html
  • Close, J., & Long, C.O. (2012). Delirium: Opportunity for comfort in palliative care. Journal of Hospice and Palliative Nursing, 14(6), 386-394.
  • Coyne, P.J., Bobb, B., & Panke, J.T. (2011). Symptom management. In J.P. Coyne & J.T. Pankem (Eds.), Conversations in palliative care (3rd ed.) (pp. 83-92). Pittsburgh, PA: Hospice and Palliative Nurses Association.
  • Economou, D.C. (2010). Bowel management: Constipation, diarrhea, obstruction and ascites. In B.R. Ferell & N. Coyle (Eds.), Oxford textbook of palliative nursing (3rd ed.) (pp. 268-289). Oxford, NY: Oxford University Press.
  • Electronic Code of Federal Regulations. (2008). Subpart C- Condition of participation: Patient’s rights. In Title 42: Public Health, Part 418- Hospice Care (73 FR 32204). Washington, DC: U.S. Government and Printing Office. Retrieved from
  • http://www.ecfr.gov/cgi-bin/text-idx?c=ecfr&sid=818258235647b14d2961ad30fa3e68e6&rgn=div5&view=text&node=42:3.0.1.1.5&idno=42
  • End of Life/Palliative Education Resource Center. (2009). Fast Fact #145: Panic disorder at the end of life. Retrieved from http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_145.htm
  • Graves, M.L., & Sun, V. (2013). Providing quality wound care at the end of life. Journal of Hospice and Palliative Nursing, 15(2) 66-74. Retrieved from http://www.medscape.com/viewarticle/780776_4
  • Hughes, R.G., Bakos, A.D., & O’Mara, A, et al. (2005). Palliative wound care at the end of life. Home Health Care Management & Practice, 17(3), 196-202. Retrieved from http://www.ahrq.gov/professionals/systems/long-term-care/resources/coordination/wound/index.html#contents 
  • Inouye,S.K., van Dyck, C.H., Alessi, C.A., Balkin, S., Siegal, A.P., & Horwitz, R.I. (1990). Clarifying confusion: The confusion assessment method, a new method for detection of delirium. Annals of Internal Medicine,113(12), 941-948.
  • McDonald, A., & Lesage, P. (2006). Palliative management of pressure ulcers and malignant wounds in patients with advanced illness. Journal of Palliative Medicine, 9(2), 285-295.
  • Montagnini, M.L., & Moat, M.E. (2004). Non pain symptom management in palliative care. Clinics in Family Practice, 6(2), 413, 416.
  • National Cancer Institute. (n.d.). Gastrointestinal complications PDQ #6: Constipation. Retrieved from http://www.cancer.gov/cancertopics/pdq/supportivecare/gastrointestinalcomplications/HealthProfessional/page2
  • National Cancer Institute. (n.d.). End of life PDQ #7: Symptom management. Retrieved from http://www.cancer.gov/cancertopics/pdq/supportivecare/lasthours/healthprofessional/page2
  • National Cancer Institute. (n.d.). Adjustment to Cancer: Anxiety and distress PDQ #8- Screening and assessment.  Retrieved from http://www.cancer.gov/cancertopics/pdq/supportivecare/adjustment/HealthProfessional/page4
  • National Cancer Institute. (n.d.). End of life PDQ #10: Supportive and palliative care– nausea and vomiting.  Retrieved from http://www.cancer.gov/cancertopics/pdq/supportivecare/nausea/HealthProfessional/page1 
  • National Cancer Institute. (n.d.). PDQ #11: Nausea,vomiting (emesis), constipation, and bowel obstruction in advanced Cancer. Retrieved from http://www.cancer.gov/cancertopics/pdq/supportivecare/nausea/HealthProfessional/page7#Reference7.5
  • National Cancer Institute. (n.d.). PDQ#12: Last days of life. Retrieved from http://www.cancer.gov/cancertopics/pdq/supportivecare/lasthours/patient/page1/AllPages/Print
  • National Consensus Project for Quality Palliative Care. (2013). Clinical practice guidelines for quality palliative care. Retrieved from http://www.nationalconsensusproject.org/Guidelines_Download2.aspx
  • Pasacreta, J.V., Minarik, P.A., & Nield-Anderson, l. (2010). Anxiety and depression. In B.R. Ferrell & N. Coyle (Eds.), Oxford Textbook of Palliative Nursing (3rd ed.) (pp. 425-448). Oxford, NY: Oxford University Press.
  • Qaseem, A., Snow, V., Shekelle, P., Casey, D.E., Cross, J.T., & Owens, D.K. (2008). Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: A clinical practice guideline from the American college of Physicians. Annals of Internal Medicine, 148, 141-146. Retrieved from http://annals.org/article.aspx?articleid=738967
  • Registered Nurses’ Association of Ontario. (2011). End-of-life care during the last days and hours. Retrieved from
  • http://rnao.ca/bpg/guidelines/endoflife-care-during-last-days-and-hours
  • Ross, D.D., & Alexander, C.S. (2001). Management of common symptoms in terminally ill patients: Part II. Constipation, delirium and dyspnea. American Family Physician, 64(6), 1019-1027. Retrieved from http://www.aafp.org/afp/2001/0915/p1019.html
  • Ross, D.D., & Alexander, C.S. (2001). Management of common symptoms in terminally ill patients: Part I. Fatigue, anorexia, cachexia, nausea and vomiting. American Family Physician, 64(5). Retrieved from http://www.aafp.org/afp/2001/0901/p807.html
  • Steis, M.R., Evans, L., Hirschman, K.B., Hanlon, A., Fick, D.M., Flanagan, N., & Inouye, S.K. (2012). Screening for delirium using caregivers: Convergent validity of the caregiver Confusion Assessment Method and interviewer-rated Confusion Assessment Method. Journal of the American Geriatrics Society.
  • Widera, E.W., & Block, S.D. (2012). Managing grief and depression at the end of life. American Family Physician, 86(3), 259-264. Retrieved from http://www.aafp.org/afp/2012/0801/p259.html
  • Wilders, H., & Menten, J. (2002). Death rattle: Prevalence, prevention and treatment. Journal of Pain and Symptom Management, 23(4), 310-317.
Dyspnea
  • American Thoracic Society. (1999). Dyspnea: Mechanisms, assessment, and management- A consensus statement. American Journal of Respiratory Critical Care Medicine, 159, 321-340. Retrieved from
  • http://www.thoracic.org/statements/resources/archive/dyspnea1-20.pdf
  • Campbell, M.L. (2010). Assessing respiratory distress when the patient cannot report dyspnea. Nursing Clinics of North America, 45, 363–373. Retrieved from http://www.nursingconsult.com/nursing/journals/0029-6465/full-text/PDF/s0029646510000277.pdf?issn=0029-6465&full_text=pdf&pdfName=s0029646510000277.pdf&spid=23612993&article_id=762674
  • Campbell, M.L., Templin, T., & Walch, J. (2010). A respiratory distress observation scale for patients unable to self-report dyspnea. Journal of Palliative Medicine, 13(3), 285-290. 
  • Vancouver Island Health Authority. (2005). S.O.S. for S.O.B. Retrieved from http://www.viha.ca/NR/rdonlyres/07F22ADB-B323-4A57-8ADF-F7208DE9C107/0/sos_for_sob.pdf
  • Center for Medicare and Medicaid Services. (2014). Guidance manual for completion of the Hospice Item Set (HIS). Retrieved from http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Downloads/HIS-Manual.pdf
  • Chang, V.T., Hwang, S.S., Feuerman, M., Kasimis, B.S., & Thaler, H.T. (2000). The memorial symptom assessment scale short form (MSAS-SF). Cancer, 89(5), 1162-1171.
  • Dorman, S., et. al.(2009). Researching breathlessness in palliative care: Consensus statement of the National Cancer Research Institute Palliative Care Breathlessness Subgroup.  Palliative Medicine, 23, 213–227. Retrieved from http://www.ipac.org/fileadmin/user_upload/publikation/Dorman-2009.pdf
  • Electronic Code of Federal Regulations. (2008). Subpart C- Condition of participation: Initial and comprehensive assessment of the patient. In Title 42: Public Health, Part 418- Hospice Care (73 FR 32204). Washington, DC: U.S. Government and Printing Office. Retrieved from http://www.ecfr.gov/cgi-bin/text-idx?c=ecfr&rgn=div5&view=text&node=42:3.0.1.1.5&idno=42#42:3.0.1.1.5.2.3.5
  • Institute for Clinical Systems Improvement. (2013). Palliative care for adults. Retrieved from https://www.icsi.org/_asset/k056ab/PalliativeCare.pdf
  • Maxwell, T.L. (2007). The role of opioids in reducing dyspnea. Hospice Pharmacia Evidence Matters Newsletter, 1(2). Retrieved from evhttp://www.hospicepharmacia.com/assets/pdf/evidencematters0407.pdf
  • Mularski, R.A., Campbell, M.L., Asch, S.M., Reeve, B.B., Basch, E., Maxwell, T.L., Hoverman, J.R., Cuny, J., Clauser, S.B., Snyder, C., Seow, H., Wu, A.W., & Dy, S. (2010). A review of quality of care evaluation for the palliation of dyspnea. American Journal of Respiratory and Critical Care Medicine, 181(6), 534-538. Retrieved from http://www.effectivehealthcare.ahrq.gov/ehc/products/204/462/CER25%20for%20posting.pdf
  • National Cancer Institute. (2014). Last days of life PDQ #1:  End of life symptom management. Retrieved from http://www.cancer.gov/cancertopics/pdq/supportivecare/lasthours/healthprofessional
  • National Cancer Institute. (2014). Pain PDQ #2:  Pharmacologic management. Retrieved from http://www.cancer.gov/cancertopics/pdq/supportivecare/pain/HealthProfessional
  • Newton, P.J., et.al. (2008). Nebulized furosemide for the management of dyspnea: Does the evidence support its use? Journal of Pain and Symptom Management, 36(4). 
  • Philip, J, Smith, W.B., Craft, P, & Lickiss, N. (1998). Concurrent validity of the modified Edmonton Symptom Assessment System with the Rotterdam Symptom Checklist and the Brief Pain Inventory. Support Cancer Care, 6(6) 539-541.
  • Viola, R, Kiteley, C, Lloyd, N.S., Mackay, J.A., Wilson, J, & Wong, R.K. (2008). The management of dyspnea in cancer patients: A systematic review. Support Care Cancer, 16(4) 329-337. 
  • Watanabe, S.M., Nekolaichuk, C.L., & Beaumont, C. (1996). The edmonton symptom assessment system, a proposed tool for distress screening in cancer patients: Development and refinement. Psycho-Oncology, 21(9), 977-985. doi:10.1002/pon.1996
  • Webber, K., & Davies, A.N. (2011). Validity of the memorial symptom assessment scale-short form psychological subscales in advanced cancer patients. Journal of Pain and Symptom Management,42(5), 761-767.
  • Weissman, D. (n.d.). Fast Fact #27: Dyspnea at end of life. Retrieved from http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_027.htm
Pain
  • American Geriatrics Society Panel on Persistent Pain in Older Persons. (2009). Pharmacological management of persistent pain in older persons. Journal of the American Geriatrics Society, 57, 1331-1346.
  • Bieri, D., Reeve, R., Champion, G.D., Addicoat, L., & Ziegler, J. (1990). The Faces Pain Scale for the self-assessment of the severity of pain experienced by children: Development, initial validation and preliminary investigation for ratio scale properties. Pain, 41, 139-150.
  • Bjoro, K., Bergen, K., & Herr, K. (2008). Tools for pain assessment in older adults with end-stage dementia.  AAHPM Bulletin, 9(3). Retrieved from http://www.aahpm.org/pdf/08summercoverarticle.pdf
  • Breivik, H., Borchgrevink, P.C., Allen, S.M., Rosseland, L.A., Romundstad, L., Hals, E.K., Kvarstein, G., & Stubhaug, A. (2008). Assessment of pain. British Journal of Anaesthesiology, 101(1), 17-24.
  • Cavalieri, T.A. (2005). Management of pain in older adults. Journal of the American Osteopathic Association, 105(3), suppl 12S-17S.
  • Green, C.R., Anderson, K.O., Baker, T.A., Campbell, L.C., Decker, S., Fillingim, R.B., Kalauokalani, D.A., Lasch, K.E., Myers, C., Tait, R.C., Todd, K.H., & Vallerand, A.H. (2003). The unequal burden of pain: confronting racial and ethnic disparities in pain. Pain Medicine, 4(3), 277-294. 
  • Herr, K., Coyne, P.J., McCaffery, M., Manworren, R., & Merkel, S. (2011). Pain assessment in the patient unable to self-report: Position statement with clinical practice recommendations. Pain Management Nursing, 7(2), 230-250. Retrieved from http://www.aspmn.org/organization/documents/nonverbaljournalfinal.pdf
  • Hicks, C.L., von Baeyer, C.L., Spafford, P., van Korlaar, I., & Goodenough, B. (2001). The faces pain scale – revised: Toward a common metric in pediatric pain measurement. Pain, 93, 173-183.
  • Horgas, A.L., Yoon, S.L., Grall, M. (2012). Pain management. In M. Boltz, E. Capezuti, T. Fulmer, & D. Zwicker (Eds.). Evidence-based geriatric nursing protocols for best practice (4th ed.) (pp. 246-267). New York, NY: Springer Publishing Company.
  • ICSI Health Care Guideline. (2013). Assessment and management of chronic pain. Retrieved from https://www.icsi.org/_asset/bw798b/ChronicPain.pdf 
  • Leresche, L. (2011). Defining gender disparities in pain management. Clinical Orthopedics and Related Research, 469(7), 1871-1877.
  • Lukas, A., Barber, J.B., Johnson, P., & Gibson, S.J. (2013). Observer-rated pain assessment instruments improve both the detection of pain and the evaluation of pain intensity in people with dementia. European Journal of Pain, 17(10), 1558-1568.
  • National Cancer Institute. (n.d.). Pain PDQ (#3). Retrieved from http://www.cancer.gov/cancertopics/pdq/supportivecare/pain/HealthProfessional/page1
  • National Cancer Institute. (n.d.). Pain PDQ (#4): Pharmacologic management. Retrieved from http://www.cancer.gov/cancertopics/pdq/supportivecare/pain/HealthProfessional/page3
  • National Cancer Institute. (n.d.). Pain PDQ (#5): Physical, integrative, cognitive-behavioral, and psychosocial interventions. Retrieved from http://www.cancer.gov/cancertopics/pdq/supportivecare/pain/HealthProfessional/page5
  • National Cancer Institute. (n.d.). Gastrointestinal complications PDQ (#6): Constipation. Retrieved from http://www.cancer.gov/cancertopics/pdq/supportivecare/gastrointestinalcomplications/HealthProfessional/page2
  • Pasero, C, & McCaffery, M. (2011). Pain assessment and pharmacologic management. St. Louis, MO: Elsevier/Mosby.
  • Qaseem, A., Snow, V., Shekelle, P., Casey, D.E., Cross, J.T., & Owens, D.K. (2008). Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: A clinical practice guideline from the American college of Physicians. Annals of Internal Medicine, 148, 141-146. Retrieved from http://annals.org/article.aspx?articleid=738967
  • Reynolds, J.,Drew, D., & Dunwoody, C. (2013). American society for pain management nursing position statement: Pain management at the end of life. Pain Management Nursing, 14(3), 172-175. Retrieved from http://www.aspmn.org/organization/documents/PainManagementattheEndofLife_August2013.pdf
  • Shavers, V.L., Bakos, A., & Sheppard, V.B. (2010). Race, ethnicity, and pain among the U.S. adult population. Journal of Health Care for the Poor and Underserved, 21(1), 177-220.
  • Stewart, C., Leveille, S.G., Shmerling, R.H., Samelson, E.J., Bean, J.F., & Schofield, P. (2012). Management of persistent pain in older adults: The MOBILIZE Boston Study. Journal of the American Geriatrics Society, 60(11), 2081-2086.
Beliefs and Spirituality
  • Borneman, T., Ferrell, B., & Puchalski, C. (2010). Evaluation of the FICA tool for spiritual assessment. Journal of Pain and Symptom Management, 40(2), 163. Retrieved from http://prc.coh.org/pdf/EvalFICA.pdf
  • Center to Advance Palliative Care. (2007). Policies and tools for hospital palliative care programs: A crosswalk of national quality forum preferred practices. Retrieved from http://www.capc.org/capc-resources/capc_publications/nqf-crosswalk.pdf
  • Center for Medicare and Medicaid Services. (2014). Guidance manual for completion of the Hospice Item Set (HIS). Retrieved from http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Downloads/HIS-Manual.pdf
  • Chochinov H.M., Cann, B.J. (2005). Interventions to enhance the spiritual aspects of dying. Journal of Palliative Medicine, 8, Suppl 1:S103-15.
  • Lunder, U., Furlan, M., & Simoni?, A. (2011). Spiritual needs assessments and measurements. Current Opinion in Supportive and Palliative Care, 5(3), 273-278.
  • National Consensus Project for Quality Palliative Care. (2009). Clinical practice guidelines for quality palliative care (2nd ed.). Pittsburgh, PA: National Consensus Project for Quality Palliative Care. Retrieved from http://www.nationalconsensusproject.org/guideline.pdf
  • Puchalski, C., & Romer, A. (2000). Taking a spiritual history allows clinicians to understand patients more fully. Journal of Palliative Medicine, 3(1), 129.
  • Selman, L., Harding, R., Gysels, M., Speck, P., & Higginson, I.J. (2011). The measurement of spirituality in palliative care and the content of tools validated cross-culturally: A systematic review. Journal of Pain Symptom Management, 41(4), 728-753.
  • Vallurupalli, M., Lauderdale, K., Balboni, M.J., Phelps, A.C., Block, S.D., Ng, A.K., Kachnic, L.A., Vanderweele, T.J., & Balboni, T.A. (2012). The role of spirituality and religious coping in the quality of life of patients with advanced cancer receiving palliative radiation therapy. The Journal of Supportive Oncology, 10(2), 81-87.
Hospice Treatment Preferences
  • Bischoff, K.E., Sudore, R., Miao, Y., Boscardin, W.J., & Smith, A.K. (2013). Advance care planning and the quality of end-of-life care in older adults. Journal of the American Geriatrics Society, 61(2), 209-214.
  • Castillo, L.S., Williams, B.A., Hooper, S.M., Sabatino, C.P., Weithorn, L.A., & Sudore, R.L. (2011). Lost in translation: The unintended consequences of advance directive law on clinical care. Annals of Internal Medicine, 154(2), 121-128.
  • Center for Medicare and Medicaid Services. (2014). Guidance manual for completion of the Hospice Item Set (HIS). Retrieved from http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Downloads/HIS-Manual.pdf
  • Chochinov, H.M., & Cann, B.J. (2005). Interventions to enhance the spiritual aspects of dying. Journal of Palliative Medicine, 8, Suppl 1:S103-15.
  • Dunn, H. (2009). Hard choices for loving people: CPR, artificial feeding, comfort care, and the patient with a life-threatening illness (5th ed.). Lansdowne, VA: A&A Publishers, Inc.
  • National Consensus Project for Quality Palliative Care. (2009). Clinical practice guidelines for quality palliative care (2nd ed.). Pittsburgh, PA: National Consensus Project for Quality Palliative Care. Retrieved from http://www.nationalconsensusproject.org/guideline.pdf
  • Selman, L., Harding, R., Gysels, M., Speck, P., & Higginson, I.J. (2011). The measurement of spirituality in palliative care and the content of tools validated cross-culturally: A systematic review. Journal of Pain Symptom Management, 41(4), 728-753.
 COPD
  • Bauldoff, G. (2009). When breathing is a burden: how to help patients with COPD. American Nurse Today, 4(9), 17-23.
  • Burt, L & Corbride, S. (2013). COPD exacerbations. American Journal of Nursing, 113(2), 34-43.
  • Centers for Disease Control and Prevention, (2014). Morbidity and mortality weekly report, September 19, 63 (37) 822-825.
  • Corbridge, S, Wilken, L, Kapella, M. & Gronkiewicz, C. (2012). An evidence-based approach to COPD: part 1. American Journal of Nursing, 112(3), 46-57.
  • Fritz, D., and McKenzie, P. (2014). Avoiding emergency department visits for COPD, pneumonia and heart failure. Home Healthcare Nurse, 32(10), 578-586.Global Initiative for Chronic Obstructive Lung Disease (2014).
  • Global strategy for diagnosis, management and prevention of chronic obstructive pulmonary disease.Updated 2014.
  • Hall, M. (2012). Chronic obstructive pulmonary disease and asthma. Home Healthcare Nurse, 30(10), 607.
  • Zhang, C., Weihong, W., Jiping, L., Xiaoxia, C., Zhang, H., Haihua, W., & Wang, X., (2013). Development and validation of a COPD self-management scale. Respiratory Care, 58(11), 1931-1936.
Heart Failure
  • Allen, L., Stevenson, L. W., et al. A. (2012). Decision making in advanced heart failure: A scientific statement from the American Heart Association. Circulation, 125(15), 1928-1952. doi: 10.1161/CIR.0b013e31824f2173
  • Artinian, N. T., Fletcher, G. F., Mozaffarian, D., Kris-Etherton, P., Van Horn, L., Lichtenstein, A. H., . . . Burke, L. E. (2010). Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults:  A scientific statement from the American Heart Association. Circulation, 122(4), 406-441. doi: 10.1161/CIR.0b013e3181e8edf1
  • Baker, L. C., Macaulay, D. S. et al. (2013). Effects of Care Management and Telehealth: A Longitudinal Analysis Using Medicare Data. Journal of the American Geriatrics Society, 61(9), 1560-7.
  • Baldonado, A., Rodriguez, L., Renfro, D., Sheridan, S. B., McElrath, M., & Chardos,  J. (2013). A home telehealth heart failure management program for veterans through care transitions. Dimensions of Critical Care Nursing, 32(4), 162-5.
  • Barnason, S., Zimmerman, L., & Young, L. (2012). An integrative review of interventions promoting self-care of patients with heart failure. Journal of Clinical Nursing, 21(3/4), 448-75.
  • Bentley, C. L., Mountain, G. A., Thompson, J., Fitzsimmons, D. A., Lowrie, K., Parker, S. G., & Hawley, M. S. (2006). A pilot randomized controlled trial of a telehealth intervention in patients with chronic obstructive pulmonary disease: Challenges of clinician-led data collection. Trials, 15, 313.
  • Berman, S. J., Minatodani, D., & Jordan, P. J. (2012). Telehealth monitoring with nurse clinician oversight. Archives of Internal Medicine, 172(20), 1612-3
  • Berry, D., Costanzo, D. M., Elliott, B., Miller, A., Miller, J. L., Quackenbush, P., (2011). Preventing avoidable hospitalizations. Home Healthcare Nurse, 29(9), 540-9.
  • Boren, S. A., Wakefield, B. J., Gunlock, T. L., & Wakefield, D. S. Heart failure self-management education: A systematic review of the evidence. International Journal of Evidence-Based Healthcare, 7(3), 159-68.
  • Chiang, L., Chen, W., Dai, Y., & Ho, Y. The effectiveness of telehealth care on caregiver burden, mastery of stress, and family function among family caregivers of heart failure patients: A quasi-experimental study. International Journal of Nursing Studies, 49(10), 1230-42.
  • Chumbler, N. R., Haggstrom, D., & Saleem, J. J. (2011). Implementation of health information technology in Veterans Health Administration to support transformational change: Telehealth and personal health records. Medical Care, 49(Suppl: S36-42)
  • Clark, A. M., Spaling, M., Harkness, K., Spiers, J., Strachan, P. H., Thompson, D. R., & Currie, K. Determinants of effective heart failure self-care: A systematic review of patients' and caregivers' perceptions. Heart, 100(9), 716-21.
  • Cleland, J. (2006). The trans-European network -- home-care management system (TEN-HMS) study: An investigation of the effect of telemedicine on outcomes in Europe. Disease Management & Health Outcomes, 14(Suppl 1), 23-28.
  • Colandrea, M., & Murphy-Gustavson, J. (2012). Patient care heart failure model: the hospitalization to home plan of care. Home Healthcare Nurse, 30(6), 337-44.
  • de Vries, A. E., de Jong, R. M., van der Wal, M. H., Jaarsma, T., van Dijk, R. B., & Hillege, H. L. (2011).  The value of innovative ICT guided disease management combined with telemonitoring in outpatient clinics for chronic heart failure patients. Design and methodology of the IN TOUCH study: A multicenter randomized trial. BMC Health Services Research, 11, 167
  • Delaney, C., Apostolidis, B. (2010). Pilot testing of a multicomponent home care intervention for older adults with heart failure: An academic clinical partnership. Journal of Cardiovascular Nursing, 25(5), E27-40.
  • Dickman, K., Carey, M., Rao, A., Worthington, A., Hilton, L., Kavanagh, R., . . . Goosage, E. Knowsley trigger tool- A tool to aid identification of heart failure patients nearing end of life and promote communication between heart failure specialist nurses and primary care. Heart, 100(Suppl 3), A26-7.
  • Domingo, M., Lupón, J., González, B., Crespo, E., López, R., Ramos, A., . . . Bayes-Genis, A. (2011). Noninvasive remote telemonitoring for ambulatory patients with heart failure: Effect on number of hospitalizations, days in hospital, and quality of life. [CARME (Catalan Remote Management Evalutation)].  Revista Española De Cardiología, 64(4), 277-85.
  • Dongtje, M. L., van der Wal, M., Stolk, R. P., Brugemann, J., Jaarsma, T., Wijtvliet, P., . . . de Greef, M. (2014). Daily physical activity in stable heart failure patients. The Journal of Cardiovascular Nursing, 29(3), 218-26.
  • Duesterhoeft, T. (2009). The future of telehealth monitoring: innovations in remote patient care and their implications for the health care industry. Caring, 28(7), 44-7.
  • Fields, J., & Wilding, M. (2013). Preventable readmissions: The care-transition crisis. Health Management Technology, 34(4), 10-1.
  • Gabrielian, S., Yuan, A., Andersen, R. M., McGuire, J., Rubenstein, L., Sapir, N., & Gelberg, L. (2013). Chronic disease management for recently homeless veterans: A clinical practice improvement program to apply home telehealth technology to a vulnerable population. Medical Care, 51(3), Suppl 1: S44-51.
  • Gellis, Z. D., & Kenaley, B. L. (2014). Integrated telehealth care for chronic illness and depression in geriatric home care patients: The Integrated Telehealth Education and Activation of Mood (I-TEAM) study. Journal of the American Geriatrics Society, 62(5), 889-95.
  • Graven, L. J., & Grant, J. S. (2014). Social support and self-care behaviors in individuals with heart failure: An integrative review. International Journal of Nursing Studies, 51(2), 320-33.
  • Graves, G. A., Ford, C. D., & Mooney, K. D. (2013). Telehealth technologies for heart failure disease management in rural areas: An integrative. Online Journal of Rural Nursing & Health Care, 13(2): 56-83.
  • Griffiths, P. C., Davis, N., Lin, J et. al. (2010).  Using telehealth technology to support family caregivers: Description of a pilot intervention and preliminary results. Physical & Occupational Therapy in Geriatrics, 28(4), 307-20.
  • Grustam, A. S., Severens, J. L., van Nijnatten, J., Koymans, R., & Vrijhoef, H. J. (2014). Cost-effectiveness of telehealth interventions for chronic heart failure patients: A literature review. International Journal of Technology Assessment in Health Care, 30(1), 59-68.
  • Guzman, J. R. (2011).  Predictors and outcomes of early adherence to the use of an asynchronous communication and monitoring telehealth device (Doctoral dissertation). University of California, Los Angeles.
  • Hall, P., & Morris, M. (2010). Improving heart failure in home care with chronic disease management and telemonitoring. Home Healthcare Nurse, 28(10), 606-19.
  • Harrison, P. L., Hara, P. A., Pope, J. E., Young, M. C., & Rula, E. Y. (2011). The impact of postdischarge telephonic follow-up on hospital readmissions. Population Health Management, 14(1), 27-32.
  • Heidenreich, P. A., Albert, N. M., Allen, L. A., Bluemke, D. A., Butler, J., Fonarow, G. C., ... Trogdon, J. G. (2013). Forecasting the impact of heart failure in the United States:  A policy statement from the American Heart Association. Circulation, 6, 606-619. Retrieved from: http://circheartfailure.ahajournals.org/content/6/3/606.full.pdf+html
  • Herr, J. K., Salyer, J., Lyon, D. E., Goodloe, L., Schubert, C., & Clement, D. G. (2014). Heart failure symptom relationships: A systematic review. The Journal of Cardiovascular Nursing, 29(5), 416-22.
  • Home monitoring cuts cardiac readmissions. (2011). Hospital Case Management, 19(5), 76-7.
  • Hsu, M. H., Chu, T. B., Yen, J. C. et al. (2010). Development and implementation of a national telehealth project for long-term care: a preliminary study. Computer Methods and Programs in Biomedicine, 97(3), 286-92.
  • Jurgens, C. Y., Shurpin, K. M., & Gumersell, K. A. (2010). Challenges and strategies for heart failure symptom management in older adults. Journal of Gerontological Nursing, 36(11), 24-33.
  • Keeping-Burke, L., Purden, M., Frasure-Smith, N., Cossette, S., McCarthy, F., & Amsel, R. (2013). Bridging the transition from hospital to home: Effects of the VITAL telehealth program on recovery for CABG surgery patients and their caregivers. Research in Nursing & Health, 36(6), 540-53.
  • Lee, C. S., Gelow, J. M., Bidwell, J. T., Mudd, J. O., Green, J. K., Jurgens, C. Y., & Woodruff-Pak, D. S. (2013). Blunted responses to heart failure symptoms in adults with mild cognitive dysfunction. Journal of Cardiovascular Nursing, 28(6), 534-40.
  • Lindenfeld, J., Albert, N. M., Boehmer, J. P., Collins, S. P., Ezekowitz, J. A., Givertz, M. M., …Walsh, M. N. (2010). Executive summary: HFSA 2010 comprehensive heart failure practice guideline. Journal of Cardiac Failure, 16. Retrieved from http://www.heartfailureguideline.org/slide_sets_all_recommendations/42
  • Lyons, M. G., & Carey, L. (2013). Parenteral inotropic therapy in the home: An update for home care and hospice. Home Healthcare Nurse, 31(4), 190-206.
  • MedlinePlus. U.S. National Library of Medicine. National Institutes of Health. (2014). Digoxin oral. Retrieved from http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682301.html
  • Meyerson, K. L.,&  Kline, K. S. (2009). Qualitative analysis of a mutual goal-setting intervention in participants with heart failure. Heart Lung, 38(1), 1-9.
  • Moser, D. K., & Watkins, J. F. (2008). Conceptualizing self-care in heart failure: a life course model of patient characteristics. The Journal of Cardiovascular Nursing, 23(3), 205-20.
  • Myers, S., Grant, R. W., Lugn, N. E., Holbert, B., & Kvedar, J. C. (2006). Impact of home-based monitoring on the care of patients with congestive heart failure. Home Health Care Management & Practice, 18(6), 444-51.
  • Paradis, V., Cossette, S. et al. (2010). The efficacy of a motivational nursing intervention based on the stages of change on self-care in heart failure patients. Journal of Cardiovascular Nursing, 25(2), 130-41.
  • Pope, R. M. (2013). Tackling long-term conditions. British Journal of Healthcare Management, (Suppl 12-6).
  • Qinglan, D., Yehle, K. S., Edwards, N. E., & Griggs, R. R. (2014). Geriatric heart failure: Awareness, evaluation, and treatment in primary care. The Journal for Nurse Practitioners, 10(1), 49-54.
  • Radhakrishnan, Kavita. (2011). Characteristics of patients on telehealth that influence their heart failure outcomes in the home-care setting (Doctoral dissertation). University of Massachusetts, Amherst.
  • Radhakrishna, K., Bowles, K., & Zettek-Sumner, A. (2013). Contributors to frequent telehealth alerts including false alerts for patients with heart failure: a mixed methods exploration. Applied Clinical Informatics, 4(4), 465-75.
  • Radhakrishnan, K., Jacelon, C. Impact of telehealth on patient self-management of heart failure: A review of literature. Journal of Cardiovascular Nursing, 27(1), 33-43.
  • Radhakrishnan, K., Jacelon, C. S., Bigelow, C., Roche, J., Marquard, J., Bowles, K. H. (2013). Use of a homecare electronic health record to find associations between patient characteristics and re-hospitalizations in patients with heart failure using telehealth. Journal of Telemedicine and Telecare, 19(2), 107-12.
  • Riegel, B., Lee, C. S., Albert, N., Lennie, T., Misook, C., Eun, K., S., . . . Moser, D. K. (2011). From novice to expert: Confidence and activity status determine heart failure self-care performance. Nursing Research, 60(2), 132-8.
  • Salyer, J., Schubert, C. M., & Chiaranai, C. (2012). Supportive relationships, self-care confidence, and heart failure self-care. Journal of Cardiovascular Nursing, 27(5), 384-93.
  • Sethares, K. A., Flimlin, H. E., & Elliot, K. M. (2014). Perceived benefits and barriers of heart failure self-care during and after hospitalization. Home Healthcare Nurse, 32(8), 482-8.    
  • Smith, A. C. (2013). Effect of Telemonitoring on Re-Admission in Patients with Congestive Heart Failure. MEDSURG Nursing, 22(1), 39-44.
  • Steventon, A., Bardsley, M., Billings, J., Dixon, J., Doll, H., Hirani, S., . . . Newman, S. (2012). Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial. The BMJ, 344(e3874). doi: http://dx.doi.org/10.1136/bmj.e3874
  • Ston, R. A., Rao, R. H., Sevick, M. A., Cheng, C., Hough, L. J., Macpherson, . . . Derubertis, F. R.
  • (2010). Active care management supported by home telemonitoring in veterans with type 2 diabetes: The DiaTel randomized controlled trial. Diabetes Care, 33(3), 478-84.
  • Strachan, P. H., Currie, K., Harkness, K., Spaling, M., & Clark, A. M. (2014). Context matters in heart failure self-care: a qualitative systematic review. Journal of Cardiac Failure, 20(6), 448-55.          
  • Takahashi, P., Pecina, J. L., Benjavan, U., Rajeev, C., Nilay, D. S., Van Houten, H., . . . Hansson, G. J. (2012). A Randomized controlled trial of telemonitoring in older adults with multiple health issues to prevent hospitalizations and emergency department visits. Archives of Internal Medicine, 172(10), 773-779.
  • Vaughan, D. V., Buck, H., & Riegel, B. (2013). Multiple Comorbid Conditions Challenge Heart Failure Self-Care by Decreasing Self-Efficacy. Nursing Research, 62(1), 2-9.
  • Veilleux, R. P., Wight, J. N., Cannon, A., Whalen. M., & Bachman, D. (2014). Home diuretic protocol for heart failure: partnering with home health to improve outcomes and reduce readmissions. The Permanente Journal, 18(3), 44-8.
  • Wilson, S. R., & Cram, P. (2012). Another sobering result for home telehealth—and where we might go next. Archives of Internal Medicine, 172(10), 779-80.
  • Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Drazner, M. H., … Wilkoff, B. L. (2013). 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. Circulation, 128, e240-e539. Retrieved from: http://circ.ahajournals.org/content/128/16/e240.short?rss=1&amp%3bssource=mfr
  • Xiang, R., Li, L., & Liu, S. X. (2013). Meta-analysis and meta-regression of telehealth programmes for patients with chronic heart failure. Journal of Telemedicine and Telecare, 19(5), 249-59.
  • Yancey, C., Jessup, M., Bozkurt, B., Butler, J., Casey, D., Drazner, M., Wilkoff, B. (2013). 2013 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. Circulation, 128, e240-e327.
Pressure Ulcers
  • Bergquist-Beringer S, Daley CM. Adapting pressure ulcer prevention for use in home health care. J Wound Ostomy Continence Nurs. 2011 Mar-Apr;38(2):145-54. doi: 10.1097/WON.0b013e31820ad115.
  • Niederhauser A, VanDeusen Lukas C, Parker V, Ayello EA, Zulkowski K, Berlowitz D. Comprehensive programs for preventing pressure ulcers: a review of the literature. Adv Skin Wound Care. 2012 Apr;25(4):167-88. Erratum in Adv Skin Wound Care. 2012 Jul;25(7):300
  • Carlsson ME, Gunningberg L. Predictors for Development of Pressure Ulcer in End-of-Life Care: A National Quality Register Study. J Palliat Med. 2016 Sep 22.
  • McInnes E, Jammali-Blasi A, Bell-Syer SE, Dumville JC, Middleton V, Cullum N. Support surfaces for pressure ulcer prevention. Cochrane Database Syst Rev. 2015 Sep 3;(9)
  • Snyder RJ, Fife C, Moore Z. Components and Quality Measures of DIME (Devitalized Tissue, Infection/Inflammation, Moisture Balance, and Edge Preparation) in Wound Care. Adv Skin Wound Care. 2016 May;29(5):205-15.
  • van Rijswijk L, Beitz JM.Ostomy Creating a pressure ulcer prevention algorithm: systematic review and face validation. Wound Manage. 2013 Nov;59(11):28-40.
  • McNichol L, Watts C, et al (2015). Identifying the right surface for the right patient at the right time: generation and content validation of an algorithm for support surface selection. J Wound Ostomy Continence Nurs.  JanFeb;42(1):19-37.
  • Padula WV, Mishra MK, Makic MB, Sullivan PW. Improving the quality of pressure ulcer care with prevention: a cost-effectiveness analysis. Med Care. 2011;49(4):385.
  • Niederhauser A, VanDeusen Lukas C, Parker V, Ayello EA, Zulkowski K, Berlowitz D. Comprehensive programs for preventing pressure ulcers: a review of the literature. Adv Skin Wound Care. 2012 Apr;25(4):167-88. Erratum in Adv Skin Wound Care. 2012 Jul;25(7):300.
  • Carlsson ME, Gunningberg L. Predictors for Development of Pressure Ulcer in End-of-Life Care: A National Quality Register Study. J Palliat Med. 2016 Sep 22. [Epub ahead of print]
  • Rachel Khoo, MBBS, and Shirley Jansen, MBChB, FRACS, FRCS, PhD The Evolving Field of Wound Measurement Techniques: A Literature Review Wounds 2016;28(6):175-181
  • Lozano-Montoya I, Vélez-Díaz-Pallarés M, Abraha I, Cherubini A, Soiza RL, O'Mahony D5, Montero-Errasquín B, Correa-Pérez A, Cruz-Jentoft AJ. Nonpharmacologic Interventions to Prevent Pressure Ulcers in Older Patients: An Overview of Systematic Reviews (The Software ENgine for the Assessment and optimization of drug and non-drug Therapy in Older peRsons [SENATOR] Definition of Optimal Evidence-Based Non-drug Therapies in Older People [ONTOP] Series). J Am Med Dir Assoc. 2016 Apr 1;17(4):370.e1-10.
  • Gillespie BM, Chaboyer WP, McInnes E, Kent B, Whitty JA, Thalib L. Repositioning for pressure ulcer prevention in adults. Cochrane Database Syst Rev. 2014 Apr 3;(4):CD009958
  • Ont Health Technol Assess Ser. 2009;9(2):1-104. Epub 2009 Apr 1. Pressure ulcer prevention: an evidence-based analysis. Health Quality Ontario. http://www.health.gov.on.ca/english/providers/program/mas/tech/tech_mn.html to review these titles that are currently available within the Pressure Ulcers series.
  • Ont Health Technol Assess Ser. 2009;9(3):1-203. Epub 2009 Jul 1. Management of chronic pressure ulcers: an evidence-based analysis. Health Quality Ontario. Abstract In April 2008, the Medical Advisory Secretariat began an evidence-based review of the literature concerning pressure ulcers. http://www.health.gov.on.ca/english/providers/program/mas/tech/tech_mn.html
  • UptoDate: Epidemiology, pathogenesis and risk assessment of pressure ulcers Author: Dan Berlowitz, MD, MPH Section Editors Kenneth E Schmader, MD Hilary Sanfey, MD Deputy Editor Kathryn A Collins, MD, PhD, FACS All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Aug 2016.
  • UpToDate, Inc. Clinical staging and management of pressure-induced injury Author: Dan Berlowitz, MD, MPH Section Editors Hilary Sanfey, MD Kenneth E Schmader, MD Deputy Editor Kathryn A Collins, MD, PhD, FACS Contributor disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Aug 2016.
  • UpToDate Prevention of pressure ulcers Author: Dan Berlowitz, MD, MPH Section Editors Kenneth E Schmader, MD Hilary Sanfey, MD Deputy Editor Kathryn A Collins, MD, PhD, FACS All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Aug 2016. | This topic last updated: May 25, 2016. 

 
Partner with referring clinicians and hospitals to develop programs and strategies to improve health outcomes and patient experience, and to help them meet accountability goals.  
By effectively engaging patients and caregivers as partners in care, home-based care organizations improve experience, activation, and ultimately, outcomes.
   
    Educate payers on opportunity to improve outcomes by more effectively care for people in their homes. Drive smarter spending by preventing admissions and avoidable ED use.
   
    Drive better outcomes by supporting practitioners to practice at the top of their license, training for excellence, and recognizing achievement.