Learning Activities Reading Assignments • Harkness, T. L. (2020). Effective care coordination
Learning Activities
Reading Assignments
• Harkness, T. L. (2020). Effective care coordination and transition management for older
adults. Nursing made Incredibly Easy! 18(5), 26-32.
doi: 10.1097/01.NME.0000694184.27758.b9
• Hirschman, K. B., Shaid, E., Bixby, M. B., Badolato, D. J., Barg, R., Byrnes, M. B., Streletz, D.,
Stretton, J., & Naylor, M. D. (2017).Transitional care in the Patient-Centered Medical Home:
Lessons in adaptation. Journal for Healthcare Quality, 39(2), 67-77.
doi:10.1097/01.JHQ.0000462685.78253.e8
• Hirschman, K., Shaid, E., McCauley, K., Pauly, M., and Naylor, M., (2015). Continuity of Care:
The transitional care model. OIJIN: The Online Journal of Issues in Nursing, (20)3.
http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Tabl
eofContents/Vol-20-2015/No3-Sept-2015/Continuity-of-Care-Transitional-Care-Model.html
• Agency for Healthcare Research and Quality [AHRQ]. (2011). Ensuring that Patient Centered
Medical Homes Effectively Serve Patients with Complex Needs.
https://pcmh.ahrq.gov/sites/default/files/attachments/EnsuringPCMHsServePts
withComplexHealthNeeds.pdf
• Karon, S., Knowles, M., Kordomenos, C., & Segelman, M. (2020). Expanding the Pace Model of
Care to high-need, high-cost population.
https://www.commonwealthfund.org/publications/issue-briefs/2020/oct/expanding-pace-
model-high-need-high-cost
• Maslow, K. & Oslander, J. G. (2012). Measurement of potentially preventable hospitalizations.
Long-Term Quality Alliance [White paper]. http://www.ltqa.org/wp-
content/themes/ltqaMain/custom/images/PreventableHospitalizations_021512_2.pdf
• Oss, M. E. (2012). Medical Home V. Health Home – Confused?
https://www.nyaprs.org/e-news-bulletins/2012/oss-medical-home-v-health-home
• Mora, K., Dorrejo, X. M., Carreon, K. M., & Butt, S. (2017). Nurse practitioner-led transitional
care interventions: an integrative review. Journal of the American Association of Nurse
Practitioners, 29, 773-790. http://dx.doi.org/10.1002/2327-6924.12509
• Naylor, M. D., Hirschman, K. B., O’Conner, M., Barg, R., and Pauly, M. V. (2013). Engaging
older adults in their transitional care: What more needs to be done? Future Medicine Part of
ESG, 2(5), 457-468. doi: 10.2217/cer.13.58. https://pubmed.ncbi.nlm.nih.gov/24236743/
Additional Resources
• Hassmiller, S. B., Lynch, D., Rick, K., & Gerrity, P. (2013). Navigating New Care Teams
[podcast].
http://www.ihi.org/knowledge/Pages/AudioandVideo/WIHINavigatingNewCareTeamswithNurse
Practitioners.aspx – (to listen to this audio, you will need to login to the IHI website)
• Robert Wood Johnson Foundation. (2018). The Green House Project: A catalyst for significant
social change .
http://www.rwjf.org/en/how-we-work/grants/grantees/the-green-house-project.html
• Robert Wood Johnson Foundation. (2013). Engaging patients in improving ambulatory care
. https://www.rwjf.org/en/library/research/2013/03/engaging-patients-in-improving-
ambulatory-care.html