Background Coronary heart disease (CHD) is the single most common cause of death
globally. However, with falling CHD mortality rates, an increasing number of people live with …

ABSTRACT BACKGROUND Patient complexity is often operationalized by counting multiple
chronic conditions (MCC) without considering contextual factors that can affect patient risk …

As policy makers seek to slow the growth in Medicare spending, they have appropriately
focused attention on beneficiaries with multiple chronic conditions. Many care coordination …

Abstract In 2006, the Centers for Medicare & Medicaid Services, which administers the
Medicare program in the United States, launched the Chronic Condition Data Warehouse …

Objective To evaluate the impact of motivational interviewing‐based health coaching on a
chronically ill group of participants compared with non‐participants. Specifically, measures …

Abstract Purpose of the Study: To identify needs encountered by older adult patients after
hospital discharge and assess the impact of a telephone transitional care intervention on …

Starfield and colleagues have suggested four overarching attributes of good primary
care:“first-contact access for each need; long-term person-(not disease) focused care; …

This systematic review examined the effectiveness of nurse care coordinator (CC) roles on
patient-reported and health service outcomes. Multiple electronic databases (Medline …

Background: Self-management of complex medication regimens for chronic illness is
challenging for many older adults. Objectives: The purpose of this study was to evaluate …

Background Heart failure is a significant problem leading to repeated hospitalizations.
Telemonitoring and hemodynamic monitoring have demonstrated success in reducing …