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The Patient Assessment of Chronic Illness Care (PACIC) has potential for use as a patient-centered measure of the implementation of the Chronic Care Model (CCM), but there is little research on the relationship between the PACIC and important behavioral and quality measures for patients with chronic conditions. To examine the relationship between PACIC(More)
OBJECTIVE To understand factors leading to all-cause 30-day readmissions in a community hospital population. RESEARCH DESIGN Structured case series of 537 readmissions using chart reviews, interviews with treating physicians, patients and family caregivers, and overall case assessment by a nurse-physician team. SETTING Eighteen Kaiser Permanente(More)
We examined the patient activation measure's (PAM's) association with process and health outcomes among adults with chronic conditions. Patients with high PAM scores were significantly more likely to perform self-management behaviors, use self-management services, and report high medication adherence, compared to patients with the lowest PAM scores. This(More)
BACKGROUND Little is known about patient perspectives of the transition from hospital to home. OBJECTIVE To develop a richly detailed, patient-centered view of patient and caregiver needs in the hospital-to-home transition. DESIGN An ethnographic approach including participant observation and in-depth, semi-structured video recorded interviews. (More)
OBJECTIVE To assess the effect of promoting a bundle of fixed doses of a generic statin and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB), delivered with minimal outpatient visits, laboratory testing, and dosage titration, to people with diabetes, coronary artery disease (CAD), or both in a large integrated healthcare(More)
OBJECTIVES (1) To determine if the Health Plan Employer Data and Information Set (HEDIS) asthma inclusion criteria consistently identify persistent asthma on a year-to-year basis and (2) to explore whether variation in the number of years of qualification is associated with medication and resource utilization outcomes. STUDY DESIGN Retrospective(More)
OBJECTIVE To examine the association between use of electronic health records (EHR) and care coordination. STUDY DESIGN Two surveys, in 2005 and again in 2006, of primary care clinicians working in a prepaid integrated delivery system during the staggered implementation of an EHR system. Using multivariate logistic regression to adjust for clinician(More)
BACKGROUND Integration of medical care across clinicians and settings could enhance the quality of care for patients. To date, there is limited data on the levels of integration in practice. Our objective was to compare primary care clinicians' perceptions of clinical integration and three sub-aspects in two healthcare systems: Kaiser Permanente, Northern(More)
OBJECTIVE To examine whether primary care team cohesion changes the association between using an integrated outpatient-inpatient electronic health record (EHR) and clinician-rated care coordination across delivery sites. STUDY DESIGN Self-administered surveys of primary care clinicians in a large integrated delivery system, collected in 2005 (N=565), 2006(More)
BACKGROUND Care coordination is essential to effective chronic care, but knowledge of processes by which health care professionals coordinate their activities when caring for chronically ill patients is limited. Electronic health records (EHRs) are expected to facilitate coordination of care, but whether they do so completely-and under what conditions-is(More)