• 1
    Report to the Congress. Medicare payment policy. 2012. Medicare Payment Advisory Commission [on-line]. Available at Accessed November 7, 2012.
  • 2
    Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009;360:14181428.
  • 3
    Coleman EA, Min SJ, Chomiak A et al. Posthospital care transitions: Patterns, complications, and risk identification. Health Serv Res 2004;39:14491465.
  • 4
    Murtaugh CM, Litke A. Transitions through postacute and long-term care settings: Patterns of use and outcomes for a national cohort of elders. Med Care 2002;40:227236.
  • 5
    Boockvar KS, Litke A, Penrod JD et al. Patient relocation in the 6 months after hip fracture: Risk factors for fragmented care. J Am Geriatr Soc 2004;52:18261831.
  • 6
    Kind AJ, Smith MA, Pandhi N et al. Bouncing-back: Rehospitalization in patients with complicated transitions in the first thirty days after hospital discharge for acute stroke. Home Health Care Serv Q 2007;26:3755.
  • 7
    Marcantonio ER, McKean S, Goldfinger M et al. Factors associated with unplanned hospital readmission among patients 65 years of age and older in a Medicare managed care plan. Am J Med 1999;107:1317.
  • 8
    Volz A, Schmid JP, Zwahlen M et al. Predictors of readmission and health related quality of life in patients with chronic heart failure: A comparison of different psychosocial aspects. J Behav Med 2011;34:1322.
  • 9
    Dicker RC, Orin DL, Han LF et al. Introducing the Medicare Quality of Care Surveillance System. Baltimore, MD: Health Care Financing Administration, 1997.
  • 10
    International Classification of Diseases, Ninth Revision, 2009. National Center for Health Statistics [on-line]. Available at Accessed February 14, 2012.
  • 11
    Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992;45:613619.
  • 12
    Nursing Home Compare. 2010. Centers for Medicare and Medicaid Services [on-line]. Available at Accessed November 10, 2010.
  • 13
    Naylor MD, Brooten DA, Campbell RL et al. Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. J Am Geriatr Soc 2004;52:675684.
  • 14
    Coleman EA, Parry C, Chalmers S et al. The care transitions intervention: Results of a randomized controlled trial. Arch Intern Med 2006;166:18221828.
  • 15
    Newcomer R, Kang T, Graham C. Outcomes in a nursing home transition case-management program targeting new admissions. Gerontologist 2006;46:385390.
  • 16
    Meador R, Chen E, Schultz L et al. Going home: Identifying and overcoming barriers to nursing home discharge. J Case Manag 2011;12:211.
  • 17
    State Level Chronic Conditions Reports. 2013. Centers for Medicaid & Medicare Services [on-line]. Available at Accessed March 26, 2013.
  • 18
    Chiu WK, Newcomer R. A systematic review of nurse-assisted case management to improve hospital discharge transition outcomes for the elderly. Prof Case Manag 2007;12:330336; quiz 337–338.
  • 19
    Naylor MD, Aiken LH, Kurtzman ET et al. The care span: The importance of transitional care in achieving health reform. Health Aff (Millwood) 2011;30:746754.
  • 20
    Toles M, Barroso J, Colon-Emeric C et al. Staff interaction strategies that optimize delivery of transitional care in a skilled nursing facility: A multiple case study. Fam Community Health 2012;35:334344.