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Mongeon, M., Levi, J., and Heinrich, J.  (2017, Nov. 6).  Elements of Accountable Communities for Health:  A Review of the Literature.  Washington:  National Academy of Medicine.  Retrieved from:  

Kruse, A., Gibbs, S., and Smith, L.  (2017, Nov.).  Advancing Medicare and Medicaid Integration:  Key Program Features and Factors Driving State Investment.  Hamilton, NJ:  CHCS Center for Health Care Strategies, Inc.  Retrieved from:  

Thomas-Henkel, C., and Schulman, M.  (2017, Oct.).  Screening for Social Determinants of Health in Populations with Complex Needs:  Implementation Considerations.  Princeton, NJ:  Robert Wood Johnson Foundation.  Retrieved from:  

Krumholz, H., and others.  (2017, Sept. 14).  Hospital-readmission risk - isolating hospital effects from patient effects.  New England Journal of Medicine.  377:1055-1064.  Retrieved from:  

(2017, Sept.).  Designing a High-Performing Health Care System for Patients with Complex Needs: Ten Recommendations for Policymakers, Expanded and Revised Edition.  New York:  The Commonwealth Fund and the London School of Economics and Political Science.  Retrieved from:  

Milstein, MD, A.  (2017, July 27).  Targeting, tailoring, and trimming chronic illness care.  New England Journal of Medicine Catalyst.  Retrieved from:  

Jones, K., and Weedon, D.  (2017, July 19).  From co-located to integrated teams:  How Utah's neurobehavior HOME program changed its culture.  New England Journal of Medicine Catalyst.  Retrieved from:  

Geva, A., and others.  (2017, July 8).  Provider Connectedness to Other Providers Reduces Risk of Readmission After Hospitalization for Heart Failure.  Thousand Oaks, CA:  Sage Publishers.  Retrieved from:  

Matheson, S., and others.  (2017, June).  Optimizing the Value of Skilled Nursing Facilities (SNFs) in Value-Based Care.  Chicago:  Leavitt Partners.  Retrieved from: 

Long, P., and others.  (2017, June).  Effective Care for High-Need Patients.  Washington:  National Academy of Medicine.  Retrieved from:  

Thompson, M., and others.  (2017, May).  Most hospitals received annual penalties for excess readmissions, but some fared better than others.  Health Affairs.  36(5):893-901.  Retrieved from:  

Wilson, A.  (2017, Apr. 20).  Adding this step to discharge planning slashes hospital readmissions by 25%.  HealthLeaders Media.  Retrieved from:

Penm, J., and others.  (2017, Mar./Apr.).  Minding the gap:  Factors associated with primary care coordination of adults in 11 countries.  The Annals of Family Medicine.  15(2):113-119.  Retrieved from: 

Sinaiko, A., Meyers, D., and Rosenthal, M.  (2017, Mar. 28).  To The Point:  Review of Medical Homes Shows Reduction in Spending for High-Risk Patients, But Design and Implementation Matter.  New York City:  The Commonwealth Fund.  Retrieved from:  

Hostetter, M., and Klein, S., and McCarthy, D.  (2017, Mar. 28).  CareMore: Improving Outcomes and Controlling Health Care Spending for High-Needs Patients.  New York City:  The Commonwealth Fund.  Retrieved from: 

Driessen, Ph.D., J., and Zhang, Ph.D., Y.  (2017, Mar. 1).  Trends in the inclusion of mental health providers in Medicare shared savings program ACOs.  Psychiatric Services. 68(3):303-305.  Retrieved from:  

Sinaiko, A., and others.  (2017, Mar.).  Synthesis of research on patient-centered medical homes brings systematic differences into relief.  Health Affairs.  36(3):500-508.  Retrieved from:  

Tobin, E., and others.  (2017, Mar.).  Behavioral Health Integration in Pediatric Primary Care.  New York:  Milbank Memorial Fund.  Retrieved from:  

Afendulis, C., and others.  (2017, Mar.).  Early impact of carefirst's patient-centered medical home with strong financial incentives.  Health Affairs.  36(3):468-475.  Retrieved from:  

Shah, R.  (2017, Mar.).  Starting small with population health management.  Healthcare Financial Management Association.  Retrieved from: 

Sinaiko, A. and others.  (2017, Mar.).  Synthesis of research on patient-centered medical homes brings systematic differences into relief.  Health Affairs.  36(3):500-508.  Retrieved from:  

(2017, Feb. 21).  Care Redesign Guide: Better Health and Lower Costs for Patients with Complex Needs.  Cambridge, MA:  Institute for Healthcare Improvement.  Retrieved from:  

McWilliams, J., and others.  (2017, Feb. 13).  Changes in Postacute Care in the Medicare Shared Savings Program.  Chicago:  American Medical Association.  Retrieved from:  

McConnell, K., and others.  (2017, Feb. 13).  Early Performance in Medicaid Accountable Care Organizations.  A Comparison of Oregon and Colorado.  Chicago:  American Medical Association.  Retrieved from: 

Colla, C., and Fisher, E.  (2017, Feb. 13).  Moving Forward with Accountable Care Organizations.  Chicago:  American Medical Association.  Retrieved from:  

Toyin, I.  (2017, Jan. 25).  Weaving whole-person health throughout an accountable care framework:  The social ACO.  Health Affairs Blog.  Retrieved from:  

Sederstrom, J.  (2017, Jan. 23).  ACOS:  Improving care through nonmedical services.  Managed Care.  Retrieved from: 

Powers, B., Donoff, B., and Jain, S.  (2017, Jan. 19). Bridging the dental divide:  Overcoming barriers to integrating oral health and primary care.  Health Affairs Blog.  Retrieved from: 

Bhattacharya, D., and Bhatt, J.  (2017).  Seven foundational principles of population health policy.  Population Health Management.  Retrieved from: 

(2017).  Integrating the Patient and Caregiver Voice into Serious Illness Care:  Proceedings of a Workshop (2017).  Chapter: Front Matter.  Washington:  The National Academies of Sciences, Engineering, and Medicine.  Retrieved from:  

(2017).  Improving Care for High-Need, High-Cost Patients.  Chicago:  ºÚÁÏÕýÄÜÁ¿ Association.  Retrieved from:  

Long, P., and others, editors.  (2017).  Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health.  Washington, DC: National Academy of Medicine.   Retrieved from:  

Mileski, M., and others. (2017). An investigation of quality improvement initiatives in decreasing the rate of avoidable 30-day, skilled nursing facility-to-hospital readmissions: A systematic review. Clinical Interventions in Aging, 12, 213-222.Retrieved from:  

Compton-Phillips, A., and Mohta, N.  (2016, Nov. 10).  Care redesign survey:  Strengthening the post-acute care connection.  NEJM Catalyst.  Retrieved from: 

Conway, P. (2016, Sept. 13).  New data:  49 states plus DC reduce avoidable hospital readmissions.  CMS Blog.  Retrieved from:  

Boccuti, C., and Casillas, G.  (2016, Sept.).  Aiming for Fewer Hospital U-Turns:  The Medicare Hospital Readmission Reduction Program.  Menlo Park, CA:  Henry J. Kaiser Family Foundation.  Retrieved from:

Chase, J.  (2016, July 22).  "Communicating Wisely":  Design, Implementation and Outcomes of an Email-Based Care Transitions Bundle.  San Diego, CA:  Society of Hospital Medicine.  Retrieved from:  

Pearl, R., and Loftus, B.  (2016, June 22).  How multi-specialty hubs fills a major gap in the care continuum.  New England Journal of Medicine.  Retrieved from:  

Cheney, C.  (2016, June 20).  How bundled payments ratchet readmission rates downward.  HealthLeaders Media.  Retrieved from:

Larson, L.  (2016, June 10).  How community health workers can improve patient outcomes.  H&HN.  Retrieved from:  

Kliff, S.  (2016, June 1).  Unpaid, stressed, and confused:  patients are the health care system's free labor.  Vox Media, Inc. Retrieved from:  

Mace, S.  (2016, May 3).  At Houston Methodist, population health is the real deal.  HealthLeaders Media.  Retrieved from:  

Rau, J.  (2016, May 2).  Hospital discharge:  It's one of the most dangerous periods for patients.  Kaiser Health News.  Retrieved from:  

Budryk, Z.  (2016, Apr. 22).  Best practices for care coordination [Special Report].  FierceHealthcare.  Retrieved from:  

Zuckerman, R., Sheingold, S., Orav, J., and others.  (2016, Apr. 21).  Readmissions, observation, and the hospital readmissions reduction program.  New England Journal of Medicine. 374:1543-1551.  Retrieved from:  

Dale, S., Ghosh, A., and Peikes, D.  (2016, Apr. 13).  Two-year costs and quality in the comprehensive primary care initiative.  New England Journal of Medicine.  Retrieved from:  

Luthra, S.  (2016, Apr. 11).  Hospitals eye community health workers to cultivate patients' successes.  Kaiser Health News.  Retrieved from:  

(2016, Apr. 11).  Comprehensive Primary Care Plus (CPC+) Fact Sheet.  Baltimore, MD:  Centers for Medicare & Medicaid Services.  Retrieved from:  

Commins, J.  (2016, Apr. 6).  Readmissions penalties still don't account for patient demographics.  HealthLeaders Media.  Retrieved from:  

Pecci, A.  (2016, Apr. 5).  Readmission prediction score validated in multi-country study.  HealthLeaders Media.  Retrieved from:  

(2016, Apr.).  Patient Centered Medical Home Resource Center.  Rockville, MD:  Agency for Healthcare Research Center.  Retrieved from:  

Gray, E., and Aronovich, R.  (2016, Apr.).  Producing an ROI with a patient-centered medical home.  Healthcare Financial Management.  Retrieved from:  

Kroch, E., Duan, M., and Martin, J., and others.  (2016, Mar./Apr.).  Patient factors predictive of hospital readmissions withing 30 days.  Journal for Healthcare Quality.  38(2):106-115.  Retrieved from:  

Compton-Phillips, A.  (2016, Mar. 31).  Care redesign report:  Why population health management is undervalued.  New England Journal of Medicine Catalyst.  Retrieved from:  

Andrews, M.  (2016, Mar. 25).  Study:  Primary care doctors often don't help patients manage depression.  Kaiser Health News.  Retrieved from:  

Boyle, M.  (2016, Mar. 23).  Collaboration With Chronic Disease Groups Optimizers Outcomes for Payers and Patients.  Health Affairs Blog.  Retrieved from:  

Budryk, Z.  (2016, Mar. 17).  Healthcare miscommunications contribute to a quarter of readmissions.  FierceHealthcare.  Retrieved from:  

Sisk, T.  (2016, Mar. 4).  Rural Hospitals embrace population health in quest for relevance.  North Carolina Health News.  Retrieved from:  

Distel, E., Casey, M., and Prasad, S.  (2016, Mar.).  Reducing Potentially-Preventable Readmissions in Critical Access Hospitals.  Policy Brief #43.  The Flex Monitoring Team.  Retrieved from:  

(2016, Mar.).  Medicaid Accountable Care Organizations:  State Update.  Trenton, NJ:  CHCS Center for Health Care Strategies, Inc.  Retrieved from:  

(2016, Mar.).  Creating Patient-Centered, Team-Based Primary Care.  Rockville, MD:  Agency for Healthcare Research Center. Retrieved from:  

Dickens, C., Weitzel, D., and Brown, S.  (2016, Mar.).  Mr. G and the revolving door:  Breaking the readmission cycle at a safety-net hospital.  Health Affairs.  35(3):540-543.  Retrieved from:  

Caspi, H.  (2016, Feb. 29).  HHS study finds reduced readmissions real, not masked as observation stays.  Healthcare Dive.  Retrieved from:  

Zuckerman, R., Sheingold, S., Orav, J., and others.   (2016, Feb. 24).  Readmissions, observation, and the hospital readmissions reduction program.  New England Journal of Medicine.  Retrieved from:  

Commins, J.  (2016, Feb. 18).  Dartmouth atlas:  Evidence-based, coordinated care for seniors elusive.  HealthLeaders Media.  Retrieved from:  

Bynum, J., Meara, E., Chang, C., and Rhoads, J.  (2016, Feb. 17).  Our Parents, Ourselves:  Health Care for an Aging Population.  LeBanon, NH:  Dartmouth Institute.  Retrieved from:  

Pecci, A.  (2016, Feb. 10).  A payer and a partner make the case for extensivists.  HealthLeaders Media.  Retrieved from:  

Mason, D.  (2016, Feb. 10).  JAMA forum:  Is 'firing" the patient an unintended consequence of value-based payment?  Journal of the American Medical Association.  Retrieved from:  

Letourneau, R.  (2016, Feb. 10).  3 payer-driven strategies to transform care models.  HealthLeaders Media.  Retrieved from:  

(2016, Feb.).  White Paper:  Developing Care Management Programs to Serve High-Need, High-Cost Populations.  St. Paul, MN:  Health Care Transformation Task Force.  Retrieved from:  

Nielsen, M., Buelt, L., Patel, K., and others.  (2016, Feb.).  The Patient-Centered Medical Home's Impact on Cost and Quality.  New York:  Milbank Memorial Fund.  Retrieved from:  

Letourneau, R.  (2016, Jan. 20).  PCMH model soaring, despite funding challenges.  HealthLeaders Media.  Retrieved from:  

DiChiara, J.  (2016, Jan. 19).  Accountable Care Organizations Renew Hospital Reimbursement; Accountable Care Organizations May Benefit Revenue Cycle Management, Especially for the Rural Hospital Community. Critical Access Hospitals May Even Become Profit Centers.  Danvers, MA:  Xtelligent Media, LLC.  Retrieved from:  

(2016, Jan. 11).  Significant Costs Involved with Converting Primary Care Medical Practices to 'Medical Homes'.  Santa Monica, CA:  Rand Corp.  Retrieved from:  

Sheingold, S., Zuckerman, R., Shartzer, A.  (2016, Jan).  Understanding Medicare hospital readmission rates and differing penalties between safety-net and other hospitals.  Health Affairs.  35(1):124-131.  Retrieved from:  

Fu, N.  (2016).  Once A Cure;  Second A Waste.  Santa Monica, CA:  Rand Corporation.  Retrieved from:  

(2016).  Committee on Educating Health Professionals to Address the Social Determinants of Health.  A Framework for Educating Health Professionals to Address the Social Determinants of Health.  Washington:  National Academies Press.  Retrieved from:  

(2016).  Committee and Accounting for Socioeconomic Status in Medicare Payment Programs and others.  Systems Practices for the Care of Socially At-Risk Populations.  Washington:  The National Academies Press.  Retrieved from:  

(2016).  Social Determinants and Collaborative Health Care:  Improved Outcomes, Reduced Costs.  Chicago:  Deloitte.  Retrieved from: