Care Coordination

by Jerome Carter on June 28, 2015

Updated  April 26, 2017     (Page is updated monthly on the 26th. For more frequent resource alerts, follow EHR Science on Twitter: @ehrscience.)

Books
AHRQ
Care Coordination Measures Atlas, 2014 Update

Reports
AHRQ
Health IT-Enabled Care Coordination and Redesign in Tennessee, 2015
A Critical Analysis of Care Coordination Strategies for Children With Special Health Care Needs, 2007

American Nurses Association
Framework for Measuring Nurses’ Contributions to Care Coordination, 2013

Improving Chronic Illness Care
Reducing Care Fragmentation: A Toolkit for Coordinating Care, 2011

Institute for Health Care Improvement
Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs, 2011

Qualis Health
Safety Net Medical Home Initiative Project – Care Coordination: Reducing Care Fragmentation in Primary Care, 2013

ONC
Improving Hospital Transitions and Care Coordination Using Automated Admission, Discharge and Transfer Alerts: A Learning Guide, 2013

Web Sites
AHRQ
Care Coordination

American Academy of Pediatrics
Care Coordination Resources

American College of Physicians
High Value Care Coordination Project

CMS
Comprehensive Primary Care Plus RAF (contains HIT Criteria)

HIMSS
Care Coordination Resource Centers

Rural Assistance Center
Rural Care Coordination Toolkit

Posts
Care Coordination and Clinical Care Systems: A Look at Clinical Work Support Needs
Blackboard: An Architectural Pattern for Supporting Care Coordination?

Key Articles
Bates DW. Health Information Technology and Care Coordination: The Next Big Opportunity for Informatics? Yearb Med Inform. 2015 Aug 13;10(1):11-4.

Morton S, Shih SC, Winther CH, Tinoco A, Kessler RS, Scholle SH. Health IT-Enabled Care Coordination: A National Survey of Patient-Centered Medical Home Clinicians. Ann Fam Med. 2015 May-Jun;13(3):250-6.

Articles [New  March  27 – April 26, 2017] [E] = e-pub date
Ranade-Kharkar P, Weir C, Norlin C, Collins SA, Scarton LA, Baker GB, Borbolla D, Taliercio V, Del Fiol G. Information needs of physicians, care coordinators, and families to support care coordination of children and youth with special health care needs (CYSHCN). J Am Med Inform Assoc. 2017 Mar 24.[E]

Sharma N, O’Hare K, O’Connor KG, Nehal U, Okumura MJ. Care Coordination and Comprehensive Electronic Health Records are Associated with Increased Transition  Planning Activities. Acad Pediatr. 2017 Apr 18. pii: S1876-2859(17)30161-4.[E]

Klein DM, Pham K, Samy L, Bluth A, Nazi KM, Witry M, Klutts JS, Grant KM, Gundlapalli AV, Kochersberger G, Pfeiffer L, Romero S, Vetter B, Turvey CL. The Veteran-Initiated Electronic Care Coordination: A Multisite Initiative to Promote and Evaluate Consumer-Mediated Health Information Exchange. Telemed J E Health. 2017 Apr;23(4):264-272.

Leahy IC, Borczuk R, Ferrari LR. Making the pediatric perioperative surgical home come to life by leveraging existing health information technology. Curr Opin Anaesthesiol. 2017 Mar 11. [E}

Shahian DM, McEachern K, Rossi L, Chisari RG, Mort E. Large-scale implementation of the I-PASS handover system at an academic medical centre. BMJ Qual Saf. 2017 Mar 9. [E]

Anderson MO, Jackson SL, Oster NV, Peacock S, Walker JD, Chen GY, Elmore JG. Patients Typing Their Own Visit Agendas Into an Electronic Medical Record: Pilot  in a Safety-Net Clinic. Ann Fam Med. 2017 Mar;15(2):158-161.

Ivory CH, Freytsis M, Lagrew DC Jr, Magee D, Vallejo M, Hasley S. Standardizing Maternity Care Data to Improve Coordination of Care. J Obstet Gynecol Neonatal Nurs. 2017 Mar – Apr;46(2):284-291

Giles SJ, Reynolds C, Heyhoe J, Armitage G. Developing a patient-led electronic feedback system for quality and safety within Renal PatientView. J Ren Care. 2017 Mar;43(1):37-49.

Alpert JM, Krist AH, Aycock RA, Kreps GL. Designing User-Centric Patient  Portals: Clinician and Patients’ Uses and Gratifications. Telemed J E Health. 2017 Mar;23(3):248-253.

Sorondo B, Allen A, Fathima S, Bayleran J, Sabbagh I. Patient Portal as a Tool for Enhancing Patient Experience and Improving Quality of Care in Primary Care Practices. EGEMS (Wash DC). 2017 Jan 26;4(1):1262.

Klabunde CN, Haggstrom D, Kahn KL, Gray SW, Kim B, Liu B, Eisenstein J, Keating NL. Oncologists’ perspectives on post-cancer treatment communication and care coordination with primary care physicians. Eur J Cancer Care (Engl). 2017 Jan 10. [E]

Milani RV, Lavie CJ, Bober RM, Milani AR, Ventura HO. Improving Hypertension Control and Patient Engagement Using Digital Tools. Am J Med. 2017 Jan;130(1):14-20.

Durcinoska I, Young JM, Solomon MJ. Patterns and predictors of colorectal cancer care coordination: A population-based survey of Australian patients. Cancer. 2017 Jan 1;123(2):319-326.

Higgins T, Larson E, Schnall R. Unraveling the meaning of patient engagement: A concept analysis. Patient Educ Couns. 2017 Jan;100(1):30-36.

Rathert C, Mittler JN, Banerjee S, McDaniel J. Patient-centered communication in the era of electronic health records: What does the evidence say? Patient Educ Couns. 2017 Jan;100(1):50-64.

2016
Data to Improve Coordination of Care. J Obstet Gynecol Neonatal Nurs. 2016 Dec 13. pii: S0884-2175(16)30425-7. [E]

Atzema CL, Maclagan LC. The transition of care between emergency department and primary care: A scoping study. Acad Emerg Med. 2016 Oct 31. [E]

Klein DM, Pham K, Samy L, Bluth A, Nazi KM, Witry M, Klutts JS, Grant KM, Gundlapalli AV, Kochersberger G, Pfeiffer L, Romero S, Vetter B, Turvey CL. The Veteran-Initiated Electronic Care Coordination: A Multisite Initiative to Promote and Evaluate Consumer-Mediated Health Information Exchange. Telemed J E Health. 2016 Oct 11. [E]

Dossett LA, Hudson JN, Morris AM, Lee MC, Roetzheim RG, Fetters MD, Quinn GP. The primary care provider (PCP)-cancer specialist relationship: A systematic review and mixed-methods meta-synthesis. CA Cancer J Clin. 2016 Oct 11. [E]

Klein DM, Pham K, Samy L, Bluth A, Nazi KM, Witry M, Klutts JS, Grant KM, Gundlapalli AV, Kochersberger G, Pfeiffer L, Romero S, Vetter B, Turvey CL. The Veteran-Initiated Electronic Care Coordination: A Multisite Initiative to Promote and Evaluate Consumer-Mediated Health Information Exchange. Telemed J E Health. 2016 Oct 11. [E]

Brouwers MC, Vukmirovic M, Tomasone JR, Grunfeld E, Urquhart R, O’Brien MA, Walker M, Webster F, Fitch M. Documenting coordination of cancer care between primary care providers and oncology specialists in Canada. Can Fam Physician. 2016 Oct;62(10):e616-e625.

Easley J, Miedema B, Carroll JC, Manca DP, O’Brien MA, Webster F, Grunfeld E. Coordination of cancer care between family physicians and cancer specialists: Importance of communication. Can Fam Physician. 2016 Oct;62(10):e608-e615.

Mcinnes S, Peters K, Bonney A, Halcomb E. A qualitative study of collaboration in general practice: Understanding the general practice nurse’s role. J Clin Nurs. 2016 Sep 29.

King RJ, Garrett N, Kriseman J, Crum M, Rafalski EM, Sweat D, Frazier R, Schearer S, Cutts T. A Community Health Record: Improving Health Through Multisector Collaboration, Information Sharing, and Technology. Prev Chronic Dis. 2016 Sep 8;13:E122.

Durcinoska I, Young JM, Solomon MJ. Patterns and predictors of colorectal cancer care coordination: A population-based survey of Australian patients. Cancer. 2016 Sep 7. [E]

Gross AH, Leib RK, Tonachel A, Tonachel R, Bowers DM, Burnard RA, Rhinehart CA, Valentim R, Bunnell CA. Teamwork and Electronic Health Record Implementation: A Case Study of Preserving Effective Communication and Mutual Trust in a Changing Environment. J Oncol Pract. 2016 Sep 6. [E]

Greysen SR, Magan Mendoza Y, Rosenthal J, Jacolbia R, Rajkomar A, Lee H, Auerbach A. Using Tablet Computers to Increase Patient Engagement With Electronic Personal Health Records: Protocol For a Prospective, Randomized Interventional Study. JMIR Res Protoc. 2016 Sep 6;5(3):e176.

Rashotte J, Varpio L, Day K, Kuziemsky C, Parush A, Elliott-Miller P, King JW, Roffey T. Mapping communication spaces: The development and use of a tool for analyzing the impact of EHRs on interprofessional collaborative practice. Int J Med Inform. 2016 Sep;93:2-13.

Dexter EN, Fields S, Rdesinski RE, Sachdeva B, Yamashita D, Marino M. Patient-Provider Communication: Does Electronic Messaging Reduce Incoming Telephone Calls? J Am Board Fam Med. 2016 Sep-Oct;29(5):613-9.

Wallace LS, Angier H, Huguet N, Gaudino JA, Krist A, Dearing M, Killerby M, Marino M, DeVoe JE. Patterns of Electronic Portal Use among Vulnerable Patients in a Nationwide Practice-based Research Network: From the OCHIN Practice-based Research Network (PBRN). J Am Board Fam Med. 2016 Sep-Oct;29(5):592-603.

Careyva B, Shaak K, Mills G, Johnson M, Goodrich S, Stello B, Wallace LS. Implementation of Technology-based Patient Engagement Strategies within Practice-based Research Networks. J Am Board Fam Med. 2016 Sep-Oct;29(5):581-91.

Kim TY, Marek KD. Profiling Patient Characteristics Associated With the Intensity of Nurse Care Coordination. West J Nurs Res. 2016 Aug 26. [E]

Dalal AK, Schnipper J, Massaro A, Hanna J, Mlaver E, McNally K, Stade D, Morrison C, Bates DW. A web-based and mobile patient-centered “microblog” messaging platform to improve care team communication in acute care. J Am Med Inform Assoc. 2016 Aug 18. [E]

Alhamid SM, Lee DX, Wong HM, Chuah MB, Wong YJ, Narasimhalu K, Tan TT, Low SY. Implementing electronic handover: interventions to improve efficiency, safety and sustainability. Int J Qual Health Care. 2016 Aug 10. [E]

Wolff JL, Darer JD, Berger A, Clarke D, Green JA, Stametz RA, Delbanco T, Walker J. Inviting patients and care partners to read doctors’ notes: OpenNotes and shared access to electronic medical records. J Am Med Inform Assoc. 2016 Aug 7. [E]

Oldenmenger WH, Witkamp FE, Bromberg JE, Jongen JL, Lieverse PJ, Huygen FJ, Baan MA, van Zuylen L, van der Rijt CC. To be in pain (or not): a computer enables outpatients to inform their physician. Ann Oncol. 2016 Jul 20. [E]

Fathi R, Sheehan OC, Garrigues SK, Saliba D, Leff B, Ritchie CS. Development of an Interdisciplinary Team Communication Framework and Quality Metrics for Home-Based Medical Care Practices. J Am Med Dir Assoc. 2016 Aug 1;17(8):725-729.e10.

Dombrowski W, Clay B, O’Brien JD. Electronic Health Records Quantify Previously Existing Phenomenon-Physicians Spend Hours Coordinating Care. JAMA Intern Med. 2016 Aug 1;176(8):1234-5.

Walia J, Qayumi Z, Khawar N, Dygulska B, Bialik I, Salafia C, Narula P. Physician Transition of Care: Benefits of I-PASS and an Electronic Handoff System in a Community Pediatric Residency Program. Acad Pediatr. 2016 Aug;16(6):519-23.

Watts B, Lawrence RH, Drawz P, Carter C, Shumaker AH, Kern EF. Development and Implementation of Team-Based Panel Management Tools: Filling the Gap between Patient and Population Information Systems. Popul Health Manag. 2016 Aug;19(4):232-9.

Rathert C, Mittler JN, Banerjee S, McDaniel J. Patient-centered communication in the era of electronic health records: What does the evidence say? Patient Educ Couns. 2016 Jul 25. [E]

Gosavi S, Bhagavat A. Use of Chronic Disease Registries to Optimize Cardiovascular Health. Curr Vasc Pharmacol. 2016 Jul 22. [E]

Kim TY, Marek KD, Coenen A. Identifying Care Coordination Interventions Provided to Community-Dwelling Older Adults Using Electronic Health Records. Comput Inform Nurs. 2016 Jul;34(7):303-11.

Wu FM, Rundall TG, Shortell SM, Bloom JR. Using health information technology to manage a patient population in accountable care organizations. J Health Organ Manag. 2016 Jun 20;30(4):581-96.

Hemsley B, Georgiou A, Carter R, Hill S, Higgins I, van Vliet P, Balandin S. Use of the My Health Record by people with communication disability in Australia: A review to inform the design and direction of future research. HIM J. 2016 Jun 6. [E]

Milne H, Huby G, Buckingham S, Hayward J, Sheikh A, Cresswell K, Pinnock H. Does sharing the electronic health record in the consultation enhance patient involvement? A mixed-methods study using multichannel video recording and in-depth interviews in primary care. Health Expect. 2016 Jun;19(3):602-16.

Rief JJ, Hamm ME, Zickmund SL, Nikolajski C, Lesky D, Hess R, Fischer GS, Weimer M, Clark S, Zieth C, Roberts MS. Using Health Information Technology to Foster Engagement: Patients’ Experiences with an Active Patient Health Record. Health Commun. 2016 May 25:1-10. [E]

Pillemer F, Price RA, Paone S, Martich GD, Albert S, Haidari L, Updike G, Rudin R, Liu D, Mehrotra A. Direct Release of Test Results to Patients Increases Patient Engagement and Utilization of Care. PLoS One. 2016 Jun 23;11(6):e0154743.

Anderson K, Burford O, Emmerton L. Mobile Health Apps to Facilitate Self-Care: A Qualitative Study of User Experiences. PLoS One. 2016 May 23;11(5):e0156164.

Fathi R, Sheehan OC, Garrigues SK, Saliba D, Leff B, Ritchie CS. Development of an Interdisciplinary Team Communication Framework and Quality Metrics for Home-Based Medical Care Practices. J Am Med Dir Assoc. 2016 May 20. [E]

Sarzynski E, Hashmi H, Subramanian J, Fitzpatrick L, Polverento M, Simmons M, Brooks K, Given C. Opportunities to improve clinical summaries for patients at hospital discharge. BMJ Qual Saf. 2016 May 6. [E]

Bruns EJ, Hyde KL, Sather A, Hook AN, Lyon AR. Applying User Input to the Design and Testing of an Electronic Behavioral Health Information System for Wraparound Care Coordination. Adm Policy Ment Health. 2016 May;43(3):350-68.

Dalal AK, Schnipper JL. Care team identification in the electronic health record: A critical first step for patient-centered communication. J Hosp Med. 2016 May;11(5):381-5.

Ireland AM. Leading Change: Implementation of a New Care Coordination Model. Oncol Nurs Forum. 2016 May 1;43(3):278-80.

Ahmed OI. Disease Management, Case Management, Care Management, and Care Coordination: A Framework and a Brief Manual for Care Programs and Staff. Prof Case Manag. 2016 May-Jun;21(3):137-46.

Samal L, Dykes PC, Greenberg JO, Hasan O, Venkatesh AK, Volk LA, Bates DW. Care coordination gaps due to lack of interoperability in the United States: a qualitative study and literature review. BMC Health Serv Res. 2016 Apr 22;16(1):143.

Cohen GR, Adler-Milstein J. Meaningful use care coordination criteria: Perceived barriers and benefits among primary care providers. J Am Med Inform Assoc. 2016 Apr;23(e1):e146-51.

Webber EC. Population Health and Pediatric Informatics. Pediatr Clin North Am. 2016 Apr;63(2):221-37.

Kim TY, Marek KD, Coenen A. Identifying Care Coordination Interventions Provided to Community-Dwelling Older Adults Using Electronic Health Records. Comput Inform Nurs. 2016 Mar 16. [E]

Krauss JC, Boonstra PS, Vantsevich AV, Friedman CP. Is the problem list in the eye of the beholder? An exploration of consistency across physicians. J Am Med Inform Assoc. 2016 Mar 21. [E]

Kern LM, Edwards A, Kaushal R. The Patient-Centered Medical Home and Associations With Health Care Quality and Utilization: A 5-Year Cohort Study. Ann Intern Med. 2016 Mar 15;164(6):395-405.

Schooley B, Walczak S, Hikmet N, Patel N. Impacts of mobile tablet computing on provider productivity, communications, and the process of care. Int J Med Inform. 2016 Apr;88:62-70.

Basta YL, Zwetsloot IM, Klinkenbijl JH, Rohof T, Monster MM, Fockens P, Tytgat KM. Decreasing the dispatch time of medical reports sent from hospital to primary care with Lean Six Sigma. J Eval Clin Pract. 2016 Feb 8. [E]

Garg SK, Lyles CR, Ackerman S, Handley MA, Schillinger D, Gourley G, Aulakh V, Sarkar U. Qualitative analysis of programmatic initiatives to text patients with mobile devices in resource-limited health systems. BMC Med Inform Decis Mak. 2016 Feb 6;16(1):16.

Turner C. Use of mobile devices in community health care: barriers and solutions to implementation. Br J Community Nurs. 2016 Feb 2;21(2):100-2.

Matiz LA, Robbins-Milne L, Krause MC, Peretz PJ, Rausch JC. Evaluating the Impact of Information Technology Tools to Support the Asthma Medical Home. Clin Pediatr (Phila). 2016 Feb;55(2):165-70.

Esch T, Mejilla R, Anselmo M, Podtschaske B, Delbanco T, Walker J. Engaging patients through open notes: an evaluation using mixed methods. BMJ Open. 2016 Jan 29;6(1):e010034.

Speck AL, Hess M, Baptist AP. An Electronic Asthma Self-Management Intervention for Young African American Adults. J Allergy Clin Immunol Pract. 2016 Jan-Feb;4(1):89-95.e2.

Park HS, Cho H, Kim HS. Development of a Multi-Agent m-Health Application Based on Various Protocols for Chronic Disease Self-Management. J Med Syst. 2016 Jan;40(1):36.


2015
Marcotte L, Kirtane J, Lynn J, McKethan A. Integrating Health Information Technology to Achieve Seamless Care Transitions. J Patient Saf. 2015 Dec;11(4):185-90.

Prey JE, Polubriaginof F, Kuperman GJ, Tiase V, Collins SA, Vawdrey DK. International perspectives on sharing clinical data with patients. Int J Med Inform. 2015 Nov 26. [E]

Mazurenko O, Hearld LR, Menachemi N. The relationship between the external environment and physician e-mail communication: The mediating role of health information technology availability. Health Care Manage Rev. 2015 Nov 19. [E]

Gay V, Leijdekkers P. Bringing Health and Fitness Data Together for Connected Health Care: Mobile Apps as Enablers of Interoperability. J Med Internet Res. 2015 Nov 18;17(11):e260.

Singer A, Duarte Fernandez R. The effect of electronic medical record system use on communication between pharmacists and prescribers. BMC Fam Pract. 2015 Oct 28;16(1):155.

Jhamb M, Cavanaugh KL, Bian A, Chen G, Ikizler TA, Unruh ML, Abdel-Kader K. Disparities in Electronic Health Record Patient Portal Use in Nephrology Clinics. Clin J Am Soc Nephrol. 2015 Oct 22. [E]

Watts B, Lawrence RH, Drawz P, Carter C, Shumaker AH, Kern EF. Development and Implementation of Team-Based Panel Management Tools: Filling the Gap between Patient and Population Information Systems. Popul Health Manag. 2015 Oct 6. [E]

Driscoll M, Gurka D. Using the Electronic Medical Record to Enhance Physician-Nurse Communication Regarding Patients’ Discharge Status. Nurs Adm Q. 2015 Oct-Dec;39(4):E31-7.

Biernacki PJ, Champagne MT, Peng S, Maizel DR, Turner BS. Transformation of Care: Integrating the Registered Nurse Care Coordinator into the Patient-Centered Medical Home. Popul Health Manag. 2015 Oct;18(5):330-6.

Tirodkar MA, Acciavatti N, Roth LM, Stovall E, Nasso SF, Sprandio J, Tofani S, Lowry M, Friedberg MW, Smith-McLallen A, Chanin J, Scholle SH. Lessons From Early Implementation of a Patient-Centered Care Model in Oncology. J Oncol Pract. 2015 Sep 29. [E

McGregor B, Mack D, Wrenn G, Shim RS, Holden K, Satcher D. Improving Service Coordination and Reducing Mental Health Disparities Through Adoption of Electronic Health Records. Psychiatr Serv. 2015 Sep 1;66(9):985-7.

Borycki E, Cummings E, Dexheimer JW, Gong Y, Kennebeck S, Kushniruk A, Kuziemsky C, Saranto K, Weber J, Takeda H. Patient-Centred Coordinated Care in Times of Emerging Diseases and Epidemics. Contribution of the IMIA Working Group on Patient Safety. Yearb Med Inform. 2015 Aug 13;10(1):207-15.

Rajamani S, Westra BL, A Monsen K, LaVenture M, Gatewood LC. Partnership to promote interprofessional education and practice for population and public health informatics: A case study. J Interprof Care. 2015 Aug 19:1-7. [E]

Klein DM, Fix GM, Hogan TP, Simon SR, Nazi KM, Turvey CL. Use of the Blue Button Online Tool for Sharing Health Information: Qualitative Interviews With Patients and Providers. J Med Internet Res. 2015 Aug 18;17(8):e199.

Steichen O, Gregg W. Health Information Technology Coordination to Support Patient-centered Care Coordination. Yearb Med Inform. 2015 Aug 13;10(1):34-7.

Bates DW. Health Information Technology and Care Coordination: The Next Big Opportunity for Informatics? Yearb Med Inform. 2015 Aug 13;10(1):11-4.

Séroussi B, Jaulent MC, Lehmann CU. Health Information Technology Challenges to Support Patient-Centered Care Coordination. Yearb Med Inform. 2015 Aug 13;10(1):8-10.

Rigby M, Georgiou A, Hyppönen H, Ammenwerth E, de Keizer N, Magrabi F, Scott P. Patient Portals as a Means of Information and Communication Technology Support to Patient- Centric Care Coordination – the Missing Evidence and the Challenges of Evaluation. A joint contribution of IMIA WG EVAL and EFMI WG EVAL. Yearb Med Inform. 2015 Aug 13;10(1):148-59.

Apter AJ, Bryant-Stephens T, Morales KH, Wan F, Hardy S, Reed-Wells S, Dominguez M, Gonzalez R, Mak N, Nardi A, Park H, Howell JT, Localio R. Using IT to improve access, communication, and asthma in African American and Hispanic/Latino Adults: Rationale, design, and methods of a randomized controlled trial. Contemp Clin Trials. 2015 Aug 8. [E]

Tuepker A, Zickmund SL, Nicolajski CE, Hahm B, Butler J, Weir C, Post L, Hickam DH. Providers’ Note-Writing Practices for Post-traumatic Stress Disorder at Five United States Veterans Affairs Facilities. J Behav Health Serv Res. 2015 Aug 1. [E]

Wodarski JS, Green PD. Health Information Technology: An Expanded Care Coordination in Rural Tennessee. Soc Work Public Health. 2015 Aug-Sep;30(5):431-42.

Johnson TL, Brewer D, Estacio R, Vlasimsky T, Durfee MJ, Thompson KR, Everhart RM, Rinehart DJ, Batal H. Augmenting Predictive Modeling Tools with Clinical Insights for Care Coordination Program Design and Implementation. EGEMS (Wash DC). 2015 Jul 30;3(1):1181.

Matiz LA, Robbins-Milne L, Krause MC, Peretz PJ, Rausch JC. Evaluating the Impact of Information Technology Tools to Support the Asthma Medical Home. Clin Pediatr (Phila). 2015 Jul 19. [E]

Press MJ, Gerber LM, Peng TR, Pesko MF, Feldman PH, Ouchida K, Sridharan S, Bao Y, Barron Y, Casalino LP. Postdischarge Communication Between Home Health Nurses and Physicians: Measurement, Quality, and Outcomes. J Am Geriatr Soc. 2015 Jul;63(7):1299-305.

Richardson JE, Vest JR, Green CM, Kern LM, Kaushal R; HITEC Investigators. A needs assessment of health information technology for improving care coordination in three leading patient-centered medical homes. J Am Med Inform Assoc. 2015 Jul;22(4):815-20.

Cady RG, Erickson M, Lunos S, Finkelstein SM, Looman W, Celebreeze M, Garwick A. Meeting the Needs of Children with Medical Complexity Using a TelehealthAdvanced Practice Registered Nurse Care Coordination Model. Matern Child Health J. 2015 Jul;19(7):1497-506.

Iddins BW, Frank JS, Kannar P, Curry WA, Mullins M, Hites L, Selleck C. Evaluation of Team-Based Care in an Urban Free Clinic Setting. Nurs Adm Q. 2015 Jul-Sep;39(3):254-62.

Kravitz RL. Caring for the Complex Patient: The Next Hurdle for Information Technology Is Care Coordination. J Gen Intern Med. 2015 Jun 17. [E]

Bruns EJ, Hyde KL, Sather A, Hook AN, Lyon AR. Applying User Input to the Design and Testing of an Electronic Behavioral Health Information System for Wraparound Care Coordination. Adm Policy Ment Health. 2015 Jun 10. [E]

Kanter RK, Abramson DM, Redlener I, Gracy D. The Medical Home and Care Coordination in Disaster Recovery: Hypothesis for Interventions and Research. Disaster Med Public Health Prep. 2015 Jun 5:1-7. [E]

Peters SG, Bunkers KS. Chronic care coordination. Chest. 2015 Jun 4. [E]

Ancker JS, Witteman HO, Hafeez B, Provencher T, Van de Graaf M, Wei E. The invisible work of personal health information management among people with multiple chronic conditions: qualitative interview study among patients and providers. J Med Internet Res. 2015 Jun 4;17(6):e137.

Vessey JA, McCrave J, Curro-Harrington C, DiFazio RL. Enhancing Care Coordination Through Patient- and Family-Initiated Telephone Encounters: A Quality Improvement Project. J Pediatr Nurs. 2015 Jun 3. [E]

Moncayo VM, Applegate KE, Duszak R Jr, Barron BJ, Fitz J, Halkar RK, Lee DJ, Schuster DM. The nuclear medicine therapy care coordination service: a model for radiologist-driven patient-centered care. Acad Radiol. 2015 Jun;22(6):771-8.

D’Souza MF, Davagnino J, Hastings SN, Sloane R, Kamholz B, Twersky J. Preliminary Data from the Caring for Older Adults and Caregivers at Home (COACH) Program: A Care Coordination Program for?áHome-Based Dementia Care and Caregiver Support in a Veterans Affairs Medical Center. J Am Geriatr Soc. 2015
Jun;63(6):1203-8.

Tonorezos E, Overholser L. Caring for the adult survivor of hodgkin lymphoma: highlighting the need for care coordination. JAMA Intern Med. 2015 Jun 1;175(6):1017-8.

Khurshid A, Shi L. The Role of HIT in Care Coordination in the United States. Med Care. 2015 Jun;53(6):558.
Van Cleave J, Boudreau AA, McAllister J, Cooley WC, Maxwell A, Kuhlthau K. Care coordination over time in medical homes for children with special health care needs. Pediatrics. 2015 Jun;135(6):1018-26

Sherer SA, Meyerhoefer CD, Sheinberg M, Levick D. Integrating commercial ambulatory electronic health records with hospital systems: An evolutionary process. Int J Med Inform. 2015 May 22. [E]

DeLia D, Lloyd K, Feldman CA, Cantor JC. Patterns of emergency department use for dental and oral health care: implications for dental and medical care coordination. J Public Health Dent. 2015 May 20. [E]

Morton S, Shih SC, Winther CH, Tinoco A, Kessler RS, Scholle SH. Health IT-Enabled Care Coordination: A National Survey of Patient-Centered Medical Home Clinicians. Ann Fam Med. 2015 May;13(3):250-6. [E]

Carney Moore JM, Dolansky M, Hudak C, Kenneley I. Care coordination between convenient care clinics and healthcare homes. J Am Assoc Nurse Pract. 2015 May;27(5):262-9.

Chow M, Beene M, O’Brien A, Greim P, Cromwell T, DuLong D, Bedecar D. A nursing information model process for interoperability. J Am Med Inform Assoc. 2015 May;22(3):608-14.

Puhr MI, Thompson HJ. The Use of Transitional Care Models in Patients With Stroke. J Neurosci Nurs. 2015 Apr 22. [E]

Xing J, Goehring C, Mancuso D. Care coordination program for Washington State Medicaid enrollees reduced inpatient hospital costs. Health Aff (Millwood). 2015 Apr;34(4):653-61.

Popejoy LL, Khalilia MA, Popescu M, Galambos C, Lyons V, Rantz M, Hicks L, Stetzer F. Quantifying care coordination using natural language processing and domain-specific ontology. J Am Med Inform Assoc. 2015 Apr;22(e1):e93-e103.

Jones CD, Vu MB, O’Donnell CM, Anderson ME, Patel S, Wald HL, Coleman EA, DeWalt DA. A failure to communicate: a qualitative exploration of care coordination between hospitalists and primary care providers around patient hospitalizations. J Gen Intern Med. 2015 Apr;30(4):417-24.

Pollack CE, Lemke KW, Roberts E, Weiner JP. Patient sharing and quality of care: measuring outcomes of care coordination using claims data. Med Care. 2015 Apr;53(4):317-23.

Shen MJ, Binz-Scharf M, D’Agostino T, Blakeney N, Weiss E, Michaels M, Patel S, McKee MD, Bylund CL. A mixed-methods examination of communication between oncologists and primary care providers among primary care physicians in underserved communities. Cancer. 2015 Mar 15;121(6):908-15.

Beste LA, Harp BK, Blais RK, Evans GA, Zickmund SL. Primary Care Providers Report Challenges to Cirrhosis Management and Specialty Care Coordination. Dig Dis Sci. 2015 Mar 3. [E]

Girault A, Ferrua M, Lallou B, Sicotte C, Fourcade A, Yatim F, Hebert G, Di Palma M, Minvielle E. Internet-based technologies to improve cancer care coordination: current use and attitudes among cancer patients. Eur J Cancer. 2015 Mar;51(4):551-7.

Soulakis ND, Carson MB, Lee YJ, Schneider DH, Skeehan CT, Scholtens DM. Visualizing collaborative electronic health record usage for hospitalized patients with heart failure. J Am Med Inform Assoc. 2015 Mar;22(2):299-311.

Zuchowski JL, Rose DE, Hamilton AB, Stockdale SE, Meredith LS, Yano EM, Rubenstein LV, Cordasco KM. Challenges in referral communication between VHA primary care and specialty care. J Gen Intern Med. 2015 Mar;30(3):305-11.

Bowers K, Carradus B, Hinkeldey C, Macek P, Rettinger S, Tanner M, Tietz M, Wahl D. Developing a statewide electronic public health care coordination tracking system. J Pediatr Nurs. 2015 Mar-Apr;30(2):416-20.

Haun JN, Nazi KM, Chavez M, Lind JD, Antinori N, Gosline RM, Martin TL. A participatory approach to designing and enhancing integrated health information technology systems for veterans: protocol. JMIR Res Protoc. 2015 Feb 27;4(1):e28.

Snyder CF, Frick KD, Herbert RJ, Blackford AL, Neville BA, Lemke KW, Carducci MA, Wolff AC, Earle CC. Comorbid condition care quality in cancer survivors: role of primary care and specialty providers and care coordination. J Cancer Surviv. 2015 Feb 26. [E]

Vanderboom CE, Thackeray NL, Rhudy LM. Key factors in patient-centered care coordination in ambulatory care: nurse care coordinators’ perspectives. Appl Nurs Res. 2015 Feb;28(1):18-24.

Howard SW, Bernell SL, Yoon J, Luck J, Ranit CM. Oregon’s experiment in health care delivery and payment reform: coordinated care organizations replacing managed care. J Health Polit Policy Law. 2015 Feb;40(1):245-55.

McClanahan R, Weismuller PC. School nurses and care coordination for children with complex needs: an integrative review. J Sch Nurs. 2015 Feb;31(1):34-43.

Hsiao CJ, King J, Hing E, Simon AE. The role of health information technology in care coordination in the United States. Med Care. 2015 Feb;53(2):184-90.

Haley WE, Beckrich AL, Sayre J, McNeil R, Fumo P, Rao VM, Lerma EV. Improving care coordination between nephrology and primary care: a quality improvement initiative using the renal physicians association toolkit. Am J Kidney Dis. 2015 Jan;65(1):67-79.

Scholz J. Finding the research questions for care coordination of older adults. Creat Nurs. 2015;21(1):21-5.

Wang MC, Mosen D, Shuster E, Bellows J. Association of patient-reported care coordination with patient satisfaction. J Ambul Care Manage. 2015 Jan-Mar;38(1):69-76.

Kim B, Lucatorto MA, Hawthorne K, Hersh J, Myers R, Elwy AR, Graham GD. Care coordination between specialty care and primary care: a focus group study of provider perspectives on strong practices and improvement opportunities. J Multidiscip Healthc. 2015 Jan 22;8:47-58.

Szalda DE, Jimenez ME, Long JE, Ni A, Shea JA, Jan S. Healthcare system supports for young adult patients with pediatric onset chronic conditions: a qualitative study. J Pediatr Nurs. 2015 Jan-Feb;30(1):126-32.

2014
McEnery KW. Coordinating patient care within radiology and across the enterprise. J Am Coll Radiol. 2014 Dec;11(12 Pt B):1217-25.

Graetz I, Reed M, Shortell SM, Rundall TG, Bellows J, Hsu J. The next step towards making use meaningful: electronic information exchange and care coordination across clinicians and delivery sites. Med Care. 2014 Dec;52(12):1037-41.

Baird A, Nowak S. Why primary care practices should become digital health information hubs for their patients. BMC Fam Pract. 2014 Nov 25;15:190.

Gum AM, Dautovich ND, Greene J, Hirsch A, Schonfeld L. Improving home-based providers’ communication to primary care providers to enhance care coordination. Aging Ment Health. 2014 Nov 17:1-11. [E]

Dykes PC, Samal L, Donahue M, Greenberg JO, Hurley AC, Hasan O, O’Malley TA, Venkatesh AK, Volk LA, Bates DW. A patient-centered longitudinal care plan: vision versus reality. J Am Med Inform Assoc. 2014 Nov-Dec;21(6):1082-90.

Hajewski CJ, Shirey MR. Care coordination: a model for the acute care hospital setting. J Nurs Adm. 2014 Nov;44(11):577-85.

Wagner EH, Sandhu N, Coleman K, Phillips KE, Sugarman JR. Improving care coordination in primary care. Med Care. 2014 Nov;52(11 Suppl 4):S33-8.

McCullough JM, Zimmerman FJ, Bell DS, Rodriguez HP. Electronic health information exchange in underserved settings: examining initiatives in small physician practices & community health centers. BMC Health Serv Res. 2014 Sep 21;14:415.

Heslop L, Power R, Cranwell K. Building workforce capacity for complex care coordination: a function analysis of workflow activity. Hum Resour Health. 2014 Sep 13;12:52.

Moyers PA, Metzler CA. Interprofessional collaborative practice in care coordination. Am J Occup Ther. 2014 Sep-Oct;68(5):500-5.

AHRQ updates on primary care research: care coordination measures atlas and database. Ann Fam Med. 2014 Sep-Oct;12(5):484.

Tyler A, Boyer A, Martin S, Neiman J, Bakel LA, Brittan M. Development of a discharge readiness report within the electronic health record-A discharge planning tool. J Hosp Med. 2014 Aug;9(8):533-9.

Marcon A, Bravi F, Foglino S, Angelastro A, Carretta E, Altini MP, Fantini MP, Carradori T. Continuity of care of cancer patients. Analysis of theoretical models and survey tools of continuity of care in people with a cancer diagnosis. Ann Ig. 2014 Jul-Aug;26(4):380-90.

Cook JE. The HITECH Act and electronic health records’ limitation in coordinating care for children with complex chronic conditions. J Allied Health. 2014 Summer;43(2):117-20.

Forbes TH 3rd. Making the case for the nurse as the leader of care coordination. Nurs Forum. 2014 Jul-Sep;49(3):167-70.

Hinami K, Bilimoria KY, Kallas PG, Simons YM, Christensen NP, Williams MV. Patient experiences after hospitalizations for elective surgery. Am J Surg. 2014 Jun;207(6):855-62

Cohen D. Effect of the Exclusion of Behavioral Health from Health Information Technology (HIT) Legislation on the Future of Integrated Health Care. J Behav Health Serv Res. 2014 May 8. [E]

Quinonez RB, Kranz AM, Long M, Rozier RG. Care coordination among pediatricians and dentists: a cross-sectional study of opinions of North Carolina dentists. BMC Oral Health. 2014 Apr 7;14:33.

Mosher D. A framework for patient-centred care coordination. Healthc Manage Forum. 2014 Spring;27(1 Suppl):S37-45

Bodenheimer T, Ghorob A, Willard-Grace R, Grumbach K. The 10 building blocks of high-performing primary care. Ann Fam Med. 2014 Mar-Apr;12(2):166-71.

Graetz I, Reed M, Shortell SM, Rundall TG, Bellows J, Hsu J. The association between EHRs and care coordination varies by team cohesion. Health Serv Res. 2014 Feb;49(1 Pt 2):438-52.

Lindsey K, Hayes A. Supporting care integration with Electronic Palliative Care Coordination Systems (EPaCCS). Int J Palliat Nurs. 2014 Feb;20(2):60-1.

Gutteridge DL, Genes N, Hwang U, Kaplan B; GEDI WISE Investigators, Shapiro JS. Enhancing a geriatric emergency department care coordination intervention using automated health information exchange-based clinical event notifications. EGEMS (Wash DC). 2014 Aug 22;2(3):1095.

Rudin RS, Bates DW. Let the left hand know what the right is doing: a vision for care coordination and electronic health records. J Am Med Inform Assoc. 2014 Jan-Feb;21(1):13-6.

Weeks DL, Polello JM, Hansen DT, Keeney BJ, Conrad DA. Measuring primary care organizational capacity for diabetes care coordination: the Diabetes Care Coordination Readiness Assessment. J Gen Intern Med. 2014 Jan;29(1):98-103.

Cooper SP, Heyer N, Shipp EM, Ryder ER, Hendrikson E, Socias CM, Del Junco DJ, Valerio M, Partida S. Community based research network: opportunities for coordination of care, public health surveillance, and farmworker research. Online J Public Health Inform. 2014 Oct 16;6(2):e190.

2013
Cipriano PF, Bowles K, Dailey M, Dykes P, Lamb G, Naylor M. The importance of health information technology in care coordination and transitional care. Nurs Outlook. 2013 Nov-Dec;61(6):475-89.

Van Houdt S, Heyrman J, Vanhaecht K, Sermeus W, De Lepeleire J. Care pathways across the primary-hospital care continuum: using the multi-level framework in explaining care coordination. BMC Health Serv Res. 2013 Aug 6;13:296.

Bass DM, Judge KS, Snow AL, Wilson NL, Morgan R, Looman WJ, McCarthy CA, Maslow K, Moye JA, Randazzo R, Garcia-Maldonado M, Elbein R, Odenheimer G, Kunik ME. Caregiver outcomes of partners in dementia care: effect of a care coordination program for veterans with dementia and their family members and friends. J Am Geriatr Soc. 2013 Aug;61(8):1377-86.

Casey JT, Berkowitz LL, Cashy J, Wichramasinghe N, Schaeffer AJ, Gonzalez CM. A protocol based, electronic medical record enabled care coordination system improves the timeliness and efficiency of care for patients with hematuria. J Urol. 2013 Jul;190(1):212-7.

Van Houdt S, Heyrman J, Vanhaecht K, Sermeus W, De Lepeleire J. An in-depth analysis of theoretical frameworks for the study of care coordination. Int J Integr Care. 2013 Jun 27;13:e024.

Smallman B, Dexter F, Masursky D, Li F, Gorji R, George D, Epstein RH. Role of communication systems in coordinating supervising anesthesiologists’ activities outside of operating rooms. Anesth Analg. 2013 Apr;116(4):898-903.

Schultz EM, Pineda N, Lonhart J, Davies SM, McDonald KM. A systematic review of the care coordination measurement landscape. BMC Health Serv Res. 2013 Mar 28;13:119.

Banfield M, Gardner K, McRae I, Gillespie J, Wells R, Yen L. Unlocking information for coordination of care in Australia: a qualitative study of information continuity in four primary health care models. BMC Fam Pract. 2013 Mar 13;14:34.

Berry LL, Rock BL, Smith Houskamp B, Brueggeman J, Tucker L. Care coordination for patients with complex health profiles in inpatient and outpatient settings. Mayo Clin Proc. 2013 Feb;88(2):184-94.

Samal L, Dykes PC, Greenberg J, Hasan O, Venkatesh AK, Volk LA, Bates DW. The current capabilities of health information technology to support care transitions. AMIA Annu Symp Proc. 2013 Nov 16;2013:1231

Millington-Sanders C, Nadicksbernd JJ, O’Sullivan C, Morgan T, Raleigh A, Yeun P, Ormerod G. Electronic palliative care co-ordination system: an electronic record that supports communication for end-of-life care – a pilot in Richmond, UK. London J Prim Care (Abingdon). 2013;5(2):106-10.

Haas S, Swan BA, Haynes T. Developing ambulatory care registered nurse competencies for care coordination and transition management. Nurs Econ. 2013 Jan-Feb;31(1):44-9, 43.

Sun W, Shen W, Li X, Cao F, Ni Y, Liu H, Xie G. Mining information dependency in outpatient encounters for chronic disease care. Stud Health Technol Inform. 2013;192:278-82.

2012
Looman WS, Erickson MM, Garwick AW, Cady RG, Kelly A, Pettey C, Finkelstein SM. Meaningful use of data in care coordination by the advanced practice RN: the TeleFamilies project. Comput Inform Nurs. 2012 Dec;30(12):649-54.

American College of Clinical Pharmacy, Hume AL, Kirwin J, Bieber HL, Couchenour RL, Hall DL, Kennedy AK, LaPointe NM, Burkhardt CD, Schilli K, Seaton T, Trujillo J, Wiggins B. Improving care transitions: current practice and future opportunities for pharmacists. Pharmacotherapy. 2012 Nov;32(11):e326-37.

Cipriano P. American Academy of Nursing on Policy. The imperative for patient-, family-, and population-centered interprofessional approaches to care coordination and transitional care: a policy brief by the American Academy of Nursing’s Care Coordination Task Force. Nurs Outlook. 2012 Sep-Oct;60(5):330-3.

Moore A, Fisher K. Healthcare information technology and medical-surgical nurses: the emergence of a new care partnership. Comput Inform Nurs. 2012 Mar;30(3):157-63.

Dale JA, Behkami NA, Olsen GS, Dorr DA. A multi-perspective analysis of lessons learned from building an Integrated Care Coordination Information System (ICCIS). AMIA Annu Symp Proc. 2012;2012:129-35.

Carayon P, Alyousef B, Hoonakker P, Hundt AS, Cartmill R, Tomcavage J, Hassol A, Chaundy K, Larson S, Younkin J, Walker J. Challenges to care coordination posed by the use of multiple health IT applications. Work. 2012;41 Suppl 1:4468-73.

2011
Midboe AM, Lewis ET, Cronkite RC, Chambers D, Goldstein MK, Kerns RD, Trafton JA. Behavioral medicine perspectives on the design of health information technology to improve decision-making, guideline adherence, and care coordination in chronic pain management. Transl Behav Med. 2011 Mar;1(1):35-44.

2010
Rantz MJ, Skubic M, Alexander G, Aud MA, Wakefield BJ, Galambos C, Koopman RJ, Miller SJ. Improving nurse care coordination with technology. Comput Inform Nurs. 2010 Nov-Dec;28(6):325-32.

Naik AD, Singh H. Electronic health records to coordinate decision making for complex patients: what can we learn from wiki? Med Decis Making. 2010 Nov-Dec;30(6):722-31.

Reddy SG, Babbott SF, Beasley BW, Nadkarni MM, Gertner EJ, Holmboe ES. Prevalence and functionality of electronic health records in internal medicine continuity clinics. Acad Med. 2010 Aug;85(8):1369-77.

Bates DW. Getting in step: electronic health records and their role in care coordination. J Gen Intern Med. 2010 Mar;25(3):174-6.

O’Malley AS, Grossman JM, Cohen GR, Kemper NM, Pham HH. Are electronic medical records helpful for care coordination? Experiences of physician practices. J Gen Intern Med. 2010 Mar;25(3):177-85.

Rantz MJ, Skubic M, Alexander G, Popescu M, Aud MA, Wakefield BJ, Koopman RJ, Miller SJ. Developing a comprehensive electronic health record to enhance nursing care coordination, use of technology, and research. J Gerontol Nurs. 2010 Jan;36(1):13-7.

2009
Graetz I, Reed M, Rundall T, Bellows J, Brand R, Hsu J. Care coordination and electronic health records: connecting clinicians. AMIA Annu Symp Proc. 2009 Nov 14;2009:208-12.

MacPhail LH, Neuwirth EB, Bellows J. Coordination of diabetes care in four delivery models using an electronic health record. Med Care. 2009 Sep;47(9):993-9.

Gurses AP, Xiao Y, Hu P. User-designed information tools to support communication and care coordination in a trauma hospital. J Biomed Inform. 2009 Aug;42(4):667-77.

Crossley L, Mueller L, Horstman P. Software-assisted spine registered nurse care coordination and patient triage–one organization’s approach. J Neurosci Nurs. 2009 Aug;41(4):217-24.

2008
Darkins A, Ryan P, Kobb R, Foster L, Edmonson E, Wakefield B, Lancaster AE. Care Coordination/Home Telehealth: the systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions. Telemed J E Health. 2008 Dec;14(10):1118-26.

Bolger-Harris H, Schattner P, Saunders M. Using computer based templates for chronic disease management. Aust Fam Physician. 2008 Apr;37(4):285-8.

Dang S, Remon N, Harris J, Malphurs J, Sandals L, Cabrera AL, Nedd N. Care coordination assisted by technology for multiethnic caregivers of persons with dementia: a pilot clinical demonstration project on caregiver burden and depression. J Telemed Telecare. 2008;14(8):443-7.

2007
McAllister JW, Presler E, Cooley WC. Practice-based care coordination: a medical home essential. Pediatrics. 2007 Sep;120(3):e723-33.

Wise PH, Huffman LC, Brat G. A Critical Analysis of Care Coordination Strategies for Children With Special Health Care Needs. Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun.

Casaverde NB, Douglass JM. The effect of care coordination on pediatric dental patient attendance. J Dent Child. 2007 May-Aug;74(2):124-9.

2006
LeGrow G, Brandman D. Technology-driven care coordination: using health IT to support provider pay-for-performance. AHIP Cover. 2006 Jan-Feb;47(1):56, 58-60. Erratum in: AHIP Cover. 2006 Jul-Aug;47(4):4.

Cashen MS, Bradley V, Farrell A, Murphy J, Schleyer R, Sensmeier J, Dykes PC. Exploring the impact of health information technology on communication and collaboration in acute care nursing. Stud Health Technol Inform. 2006;122:575-9.

2004
Burton LC, Anderson GF, Kues IW. Using electronic health records to help coordinate care. Milbank Q. 2004;82(3):457-81

2003
Waldo BH. Connecting for compliance: improving satisfaction and care coordination by extending the home care record to the physician. Home Healthc Nurse. 2003 Oct;21(10):674-9.

2001
Goodwin MD, Otake LR, Persing JA, Shin JH. A preliminary report of the virtual craniofacial center: development of Internet-/Intranet-based care coordination of pediatric craniofacial patients. Ann Plast Surg. 2001 May;46(5):511-5; discussion 516.

1998
Sicotte C, Denis JL, Lehoux P, Champagne F. The computer-based patient record challenges towards timeless and spaceless medical practice. J Med Syst. 1998 Aug;22(4):237-56.

1994
Moran WP, Messick C, Guerette P, Anderson R, Bradham D, Wofford JL, Velez R. A practice-based information system for multi-disciplinary care of chronically ill patients: what information do we need? The Community Care Coordination Network Database Group. Proc Annu Symp Comput Appl Med Care. 1994:585-9.