Link to College of Public Health

Interdisciplinary Transitions in Responsibility for Aging Care

Complete Resource List (pdf format)

Integrating Systems

Alkema, G.E., Shannon, G.R., & Wilber, K.H. (2003, Jul-Sep). Using interagency collaboration to serve older adults with chronic care needs: The Care Advocate Program. Family and Community Health, 26(3), 221-9.

American Association of Community Psychiatrists. (2001, August 28). AACP continuity of care guidelines: Best practices for managing transitions between levels of care (pdf format).

Anderson, &., & Knickman, J.R. (2001, Nov-Dec). Changing the chronic care system to meet people's needs. Health Affairs, 20(6), 146-160.

Applebaum, R., Straker, J., & Mehadizadeh, S., et al. (2002, Spring). Using high-intensity care management to integrate acute and long-term care services: Substitute for large scale system reform? Care Management Journals, 3(3), 113-119.

Bartels, S.J. (2004, Dec). Caring for the whole person: Integrated health care for older adults with severe mental illness and medical comorbidity. Journal of the American Geriatric Society, 52(12, Supp.), S2409-S257.

Bartels, S.J. (2003, Sep-Oct). Improving the system of care for older adults with mental illness in the United States. American Journal of Geriatric Psychiatry, 11(5), 486-497.

Bolda, E.J., & Seavey, J.W. (2001, Dec). Rural long-term care integration: Developing service capacity. Journal of Applied Gerontology, 20(4), 426-457.

Broockvar, K., & Vladeck, B.C. (2004, May). Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society, 52(5), 855-6.

Byock, I.R. (2001, Dec). End-of-life care: A public health crisis and an opportunity for managed care. American Journal of Managed Care, 7(12), 1123-1132.

Coburn, A.F. (2001, Dec). Models for integrating and managing actue and long-term care services in rural areas. Journal of Applied Gerontology, 20(4), 386-408.

Coleman, E.A. (2003, Apr). Falling through the cracks: Challenges and opportunities for improving transitional care for persons with continuous complex care needs. Journal of the American Geriatrics Society, 51(4), 549-55.

Coleman, E.A., Min, S.J., Chomiak, A., & et al. (2004, Oct).Posthospital care transitions: Patterns, complications, and risk identification. Health Services Research, 39(5), 1449-65.

Coleman, E., Smith, J., & Frank, J., et al. (2002, June 1). Development and testing of a measure designed to assess the quality of care transitions. International Journal of Integrated Care, 2.

Coleman, E.A., Smith, J.D., & Frank, J.C., et al. (2004, Nov). Preparing patients and caregivers to participate in care delivered across settings: The care transitions intervention. Journal of the American Geriatrics Society, 52(11), 1817-1825.

Coppola, S., Rosemond,C.A., & Greger, H.N., et al. (2002, Mar). Arena assessment: Evolution of teamwork for frail older adults. Topics in Geriatric Rehabilitation, 17(3), 13-28.

Dunn, S.A., Sobl, K.R., & Marx, S. (2001, Feb). Geriatric case management in an integrated care system. Journal of Nursing Administration, 31(2), 60-62.

Dyer, C.B., Hyer, K., & Feldt, K.S., et al. Frail older patient care by interdisciplinary teams: A primer for generalists. Gerontology and Geriatrics Education, 24(2), 51-62.

Enguidanos, S.M., Gibbs, Nancy, E., & Simmons, W.J., et al. (2003, May). Kaiser Permanente community partners project: Improving geriatric care management. Journal of the American Geriatric Society, 51(5), 710-714.

Fisher, H.M., & Raphael, T.G. (2003, Feb). Managed long-term care integration through care coordination. Journal of Aging and Health, 15(1), 223-245.

Gong, J., & Greenwood, R. (2003, May). Business side of PACE. Nursing Homes and Long-Term Care Management, 52(5), 60+.

Gong, J., & Greenwood, R. (2003, June). PACE community care and more. Provider, 29(6), 40-42+.

Gong, J., & McCarthy, S. (2000, May). Why should nursing homes become PACE providers? Part 1. Nursing Homes Long-Term Care Management, 49(5), 48+.

Goss, D.L., Temkin, G.H., & Kunitz, S., et al. (2004). Growing pains of integrated health care for the elderly: Lessons from the expansion of PACE. Milbank Quarterly, 82(2), 257-282.

Greenwood, R. (2001). PACE model. CME Issue Brief, 2(10), 1-8.

Jackson, B., Swanson, C., & Hicks, L.E., et al. (2000, Jan-Feb). Bridge of continuity from hospital to nursing home - part I: A proactive approach to reduce relocation stress syndrome in the elderly. Continuum Society for Social Work Leadership in Health Care, 20(1), 3-8.

Jackson, B., Swanson, C., & Hicks, L.E., et al. (2000, Jan-Feb). Bridge of continuity from hospital to nursing home - part II: A proactive approach to reduce relocation stress syndrome in the elderly. Continuum Society for Social Work Leadership in Health Care, 20(1), 3-8.

Kane, R.J., Homyak, P., & Bershadsky, B., et al. (2002, April). Consumer responses to the Wisconsin Partnership Program for elder persons: A variation on the PACE model. Journals of Gerontology: Series A: Biological Sciences and Medical Sciences, 57A(4), M250-M258.

Kettl, P. (2003, Jan). Managing Alzheimer's Disease in the new health care economy. Administration and Policy in Mental Health, 30(3), 267-273.

Kuder, L.C., Beaulieu, J., & Rowles, G.D. (2001, Dec). State and local initiatives and research questions for rural long-term care models. Journal of Applied Gerontology, 20(4), 471-479.

Lawler, K. (2001, Oct). Aging in place: Coordinating housing and health care provision for America's growing elderly population. Harvard University; Cambridge, MA; Washington D.C.: Joint Center for Housing Studies, Graduate School of Design and John F. Kennedy School of Government.

Laditka, S.B., & Jenkins, C.L. (2000, Nov). Enhancing inter-network cooperation among organizations providing mental health services to older persons. Administration and Policy in Mental Health, 28(2), 75-89.

Lee, B. (2001, Fall). Challenges facing case management in a changing social environment. Case Management Journals, 3(1), 20-24.

Lee, M.A., Brummel, S.K., & Meyer, J., & et al. (2000, Oct). Physician Orders for Life-Sustaining Treatment (POLST): Outcomes in a PACE program. Journal of the American Geriatric Society, 48(10), 1219-1225.

Luetz, W.N., Capitman, J., & Green, C.A. (2001). Limited entitlement for community care: How members use services. Journal of Aging and Social Policy, 12(3), 43-64.

Luetz, W.N., Greenlick, M.R., & Nonnenkamp, L. (2003). Linking medical care and community services: Practical models for bridging the gap. New York, N.Y.: Springer Pub.

Lynch, M., Estes, C.L., & Hernandez, M. (2005, April). Chronic care initiatives for the elderly: Can they bridge the gerontology-medicine gap? Journal of Applied Gerontology, 24 (2), 108-124.

Magilvy, J.K., & Congdon, J.G. (2000, Sep-Oct). The crisis nature of health care transitions for rural older adults. Public Health Nursing, 17(5), 336-45.

Master, R.J., & Eng, C. (2001, Nov-Dec). Integrating acute and long-term care for high-cost populations. Health Affairs, 20(6), 161-172.

Miller, E.A. (2001). Federal and state initiatives to integrate acute and long-term care: Issues and profiles. Huntington, N.Y.: Novinka Books.

Mollica, R. (2003, Feb). Coordinating services across the continuum of health, housing and supportive services. Journal of Aging and Health, 15(1), 165-188.

Mui, A.C. (2001). Program of All-Inclusive Care for the Elderly (PACE): An innovative long-term care model in the United States. Journal of Aging and Social Policy, 13(2-3), 53-67.

Nadash, P. (2004, Oct). Two models of managed long-term care: Comparing PACE with a Medicaid-only plan. Gerontologist, 44(5), 644-654.

Parry, C., Coleman, E.A., & Smith, J.D., et al. (2003). The care transitions intervention: A patient-centered approach to ensuring effective transfers between sites of geriatric care. Home Health Care Services Quarterly, 22(3), 1-17.

Peters, P., Fleuren, M., & Wijkel, D. (1997). The quality of the discharge planning process: The effect of a liaison nurse. International Journal of Quality Health Care, 9(4), 283-287.

Pierce, C.A. (2002, May-June). Program of All-Inclusive Care for the Elderly in 2002. Geriatric Nursing, 23(3), 173-174.

Roy, M.J., Herbers, J.E., & Seidman, A., et al. (2003, May). Improving patient satisfaction with the transfer of care. A randomized controlled trial. Journal of General Internal Medicine, 18(5), 364-9.

Stoesz, D. (2002). Age concerns: Innovation through care management. Journal of Aging and Social Policy, 14(3-4), 245-260.

Tichawa, U. (2002, Jan). Creating a continuum of care for elderly individuals. Journal of Gerontological Nursing, 28(1), 46-52.

University of Colorado at Denver and Health Sciences Center. Assessing the quality of preparation for post-hospital care from the patient's perspective: The Care Transitions Measure.

United States Commission on Affordable Housing and Health Facility Needs for Seniors in the 21st Century. (2002, June 30). Quiet crisis in America: A report to Congress. Washington, D.C.

Vladeck, F. (2004). Good place to grow old: New York's model for NORC supportive service programs. New York, N.Y.: United Hospital Fund of New York.

Waszynski, C.M., Murakami, W., & Lewis, M. (2000, Fall). Community care management. Advanced practice nurses as care managers. Care Management Journal, 2(3), 148-53.

Weiner, M., Callahan, C.M., & Tierney, W.M., et al. (2003, Sep. 2). Using information technology to improve the health care of older adults. Annals of Internal Medicine, 139(5, Part 2), 430-436.

Hospitals/Acute Care

Aizen, E., Swartman, R., & Clarfield, A.M. (2001, Oct). Hospitalization of nursing home residents in an acute-care geriatric department: Direct versus emergency room admission. The Israel Medical Association Journal, 3(10), 734-8.

Bellelli, G., Lucchi, E., & Magnifico, F., et al. (2005, Aug). Rehospitalization and transfers to nursing facilities in elderly patients after hip fracture surgery. Journal of the American Geriatric Society, 53(8), 1443-5.

Beresford, L. (2001). Hospital-hospice partnerships in palliative care: Creating a continuum of service. Alexandria, VA.: National and Palliative Care Organization.

Bowles, K.H. (2000, Nov). Vulnerable links in the home care referral process. Caring, 19(11), 34-7.

Bowles, K.H., Foust, J.B., & Naylor, M.D. (2003, Aug). Hospital discharge referral decision making: A multidisciplinary perspective. Applied Nursing Research, 16(3), 134-43.

Broockvar, K., Fishman, E., & Kyriacou, C.K., et al. (2004, March 8). Adverse events due to the discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities. Archives of Internal Medicine, 164(5), 545-50.

Bull, M.J., Hansen, H.E., & Gross, C.R. (2000). Differences in family caregiver outcomes by their level of involvement in discharge planning. Applied Nursing Research, 13(2), 76-82.

Bull, M.J., Lou, D., & Maruyama, G.M. (2000, Summer). Measuring continuity of elders' posthospital care. Journal of Nursing Measurement, 8(1), 41-60.

Bull, M.J., Maruyama, G.M., & Luo, D. (1995). Testing a model for posthospital transition of family caregivers for elderly persons. Nursing Research, 44(3), 132-138.

Coleman, E.A., & Mahoney, E., & Parry, C. (2005, Mar). Assessing the quality of preparation for posthospital care from the patient's perspective: The care transitions measure. Medical Care, 43(3), 246-55.

Coleman, E.A., Min, S.J., Chomiak, A., & et al. (2004, Oct). Posthospital care transitions: Patterns, complications, and risk identification. Health Services Research, 39(5), 1449-65.

Coleman, E., Smith, J., & Frank, J., et al. (2002, June 1). Development and testing of a measure designed to assess the quality of care transitions. International Journal of Integrated Care, 2.

Coleman, E.A., Smith, J.D., & Frank, J.C., et al. (2004, Nov). Preparing patients and caregivers to participate in care delivered across settings: The care transitions intervention. Journal of the American Geriatrics Society, 52(11), 1817-1825.

Cortes, T.A., Wexler, S., & Fitzpatrick, J.J. (2004, Jun). The transition of elderly patients between hospitals and nursing homes. Improving nurse-to-nurse communication. Journal of Gerontological Nursing, 30(6), 10-5.

Crotty, M., Rowett, D., & Spurling, L., et al. (2004, Dec). Does the addition of a pharmacist transition coordinator improve evidence-based medication management and health outcomes in older adults moving from the hospital to a long-term care facility? Results of a randomized, controlled trial. American Journal of Geriatric Pharmacotherapy, 2(4), 257-64.

e-Ethics (2003, July). Ethical issues in discharging the frail, elderly patient. http://www.parkridgecenter.org/ethics_july03.html.

Eveillard, M., Quenon, J.L., & Rufat, P., et al. (2001, Nov). Association between hospital-acquired infections and patients' transfers. Infection Control and Hospital Epidemiology, 22(11), 693-6.

Gilhooley, C.J. (2005) Priority focus process and tracer methodology. Joint Commission on the Accreditation of Healthcare Organizations.

Grimmer, K.A., & Moss, J. (2001). The development, validity, and application of a new instrument to assess the quality of discharge planning activities from the community perspective. International Journal of Healthcare, 13(2), 109-116.

Harrison, M.B., Brown, G.B., & Roberts, J., et al. (2002, Apr). Quality of life of individuals with heart failure: A randomized trial of the effectiveness of two models of hospital-to-home transitions. Medical Care, 40(4), 271-82.

Hruby, M., Pantilat, S.Z., & Lo, B. (2001, Dec). How do patients view the role of the primary care physician in inpatient care?, 21S-25S.

Jackson, B., Swanson, C., & Hicks, L.E., et al. (2000, Jan-Feb). Bridge of continuity from hospital to nursing home - part I: A proactive approach to reduce relocation stress syndrome in the elderly. Continuum Society for Social Work Leadership in Health Care, 20(1), 3-8.

Jackson, B., Swanson, C., & Hicks, L.E., et al. (2000, Jan-Feb). Bridge of continuity from hospital to nursing home - part II: A proactive approach to reduce relocation stress syndrome in the elderly. Continuum Society for Social Work Leadership in Health Care, 20(1), 3-8.

Lahn, M., Friedman, B., & Bijur, P., et al. (2001, Dec). Advance directives in skilled nursing facility residents transferred to emergency departments. Academic Emergency Medicine, 8(12), 1158-62.

LeCleric, C.M., Wells, D.L., & Craig, D., et al. (2002). Falling short of the mark: Tales of life after hosptial discharge. Clinical Nursing Research, 9(9), 242-63.

Lee, M.A., Brummel, S.K., & Meyer, J., & et al. (2000, Oct). Physician Orders for Life-Sustaining Treatment (POLST): Outcomes in a PACE program. Journal of the American Geriatric Society, 48(10), 1219-1225.

Liu, A.L., & Taylor, D.M. (2002, Dec). Adverse events and complications among patients admitted to hospital in the home directly from the emergency department. Emergency Medicine, 14(4), 400-5.

McKain, S., Henderson, A., & Kuys, S., et al. (2005, Jul). Exploration of patients' needs for information on arrival at a geriatric and rehabilitation unit. Journal of Clinical Nursing, 14(6), 704-10.

McKinney, A.A., & Deeny, P. (2002, Dec). Leaving the intensive care unit: A phenomenological study of the patients' experience. Intensive Critical Care Nursing, 18(6), 320-31.

Mor, V., Papandonatos, G., & Miller, S.C. (2005, Feb). End-of-life hospitalization for African American and non-Latino white nursing home residents: Variation by race and a facility's racial composition. Journal of Palliative Medicine, 8(1), 58-68.

Murtaugh, C.M., & Litke, A. (2002, Mar). Transitions through postacute and long-term care settings: Patterns of use and outcomes for a national cohort of elders. Medical Care, 40(3), 227-36.

Nasraway, S.A., Button, G.J., & Rand, W.M., et al. (2000, Jan). Survivors of catastrophic illness: Outcome after direct transfers from intensive care to extended care facilities. Critical Care Medicine, 28(1), 19-25.

Naylor, M.D. (2000). A decade of transitional care research with hospitalized elders. Journal of Cardiovascular Nursing, 14(3), 1-14.

Naylor, M.D., & Browles, K.H., & Brooten, D. (2000). Patient problems and advance practice nurse interventions during transitional care. Public Health Nursing, 17(2), 94-102.

Naylor, M.D., & Brooten, D., & Campbell, R., et al. (1999). Comprehensive follow-up of hospitalized elders. Journal of the American Medical Association, 281(7), 613-620.

Naylor, M.D., & McCauley, K. (1999). The effects of discharge planning and home follow-up intervention on elders hospitalized with common medical and surgical conditions. Journal of Cardiovascular Nursing, 14(1), 999-1006.

Naylor, M.D., & Roe-Prior, P. (1999). Transitions between acute and long term care. Advances in Long Term Care. Volume IV. New York: Springer, 1-22.

New research establishes importance of specialty care after discharge for an MI. (2003, Apr). Disease Management Advisor, 9(4), 61-3, 50.

Odell, M. (2000, Feb). The patient's thoughts and feelings about their transfer from intensive care to the general ward. Journal of Advanced Nursing, 31(2), 322-9.

Pauls, M.A., Singer, P.A., & Dubinsky, I. (2001, Jul). Communicating advance directives from long-term care facilities to emergency departments. Journal of Emergency Medicine, 21(1), 83-9

Pekmezaris, R., Breuer, L., & Zaballero, A., et al. (2004, Feb). Predictors of site of death of end-of-life patients: The importance of specificity in advance directives. Journal of Palliative Medicine, 7(1), 9-17.

Purdy, W. (2002, Nov-Dec). Nursing home to emergency room? The troubling last transfer. Hastings Center Report, 32(6), 46-8.

Roy, C.L., Poon, E.G., & Karson, A.S., et al. (2005, July 19). Patient safety concerns arising from test results that return after hospital discharge. Annals of Internal Medicine, 143(2), 121-128.

Sales, A.E., Pineros, S.L., & Magid, D.J., et al. (2005, Jan). The association between clinical integration of care and transfer of veterans with acute coronary syndromes from primary care VHA hospitals. BMC Health Services Research, 5(1), 2

Saliba, D., Kingston, R., & Buchanan, J., et al. Appropriateness of the decision to transfer nursing facility residents to the hospital. Journal of the American Geriatric Association, 48(2), 154-63.

Sheehan, M. (2004, Nov). Palliative care: Hospice and hospital collaboration. Caring, 23(11), 38-41.

Terrell, K.M., Brizendine, E.J., & Bean, W.F., et al. (2005, Feb). An extended care facility-to-emergency department transfer form improves communication. Academic Emergency Medicine, 12(2), 114-8.

Tracers: They're not just for accreditation surveys.(2005, Aug). ED Management, 17(8), 88-9

Turnbull, G.B. (2002, Dec). Connecting the disconnect between hospital and home. Ostomy Wound Management, 48(12), 14, 16.

Van Walraven, C., Mamdani, M., & Fang, J., et al. (2004, Jun). Continuity of care and patient outcomes after hospital discharge. Journal of General Internal Medicine, 19(6), 624-31.

Van Walraven, C., Seth, R., & Austin, P.C., et al. (2002, Mar). Effect of discharge summary availability during post-discharge visits on hospital readmission. Journal of General Internal Medicine, 17(3), 86-92.

Young, M.P., Gooder, V.M., & McBrider, K., et al. (2003, Feb). Inpatient transfers to the intensive care unit: Delays are associated with increased mortality and morbidity. Journal of General Internal Medicine, 18(2), 77-83.

University of Colorado at Denver and Health Sciences Center. Assessing the quality of preparation for post-hospital care from the patient's perspective: The Care Transitions Measure.

Primary Care/Outpatient Medicine

Dyer, C.B., Hyer, K., & Feldt, K.S., et al. Frail older patient care by interdisciplinary teams: A primer for generalists. Gerontology and Geriatrics Education, 24(2), 51-62.

Fortinsky, R.H., Unson, C.G., & Garcia, R.I. (2002, Jun). Helping family caregivers by linking primary care physicians with community-based dementia care services: The Alzheimer's Service Coordination Plan. Dementia, 1(2), 227-240.

Gandhi, T.K. (2005, Mar 1). Fumbled handoffs: One dropped ball after another. Annals of Internal Medicine, 142(5), 352-8.

Hruby, M., Pantilat, S.Z., & Lo, B. (2001, Dec). How do patients view the role of the primary care physician in inpatient care?, 21S-25S.

Kane, R.L., Homyak, P., & Bershadsky, B., et al. (2002, Apr). Consumer responses to the Wisconsin Partnership Program for elderly persons: A variation on the PACE model. Journals of Gerontology: Series A - Biological Sciences and Medical Sciences, 57A(4), M250-M258.

Laditka, S.B., Jenkins, C.L., & Trevisani, G., et al. (2001). Doctor on the patient's turf: Assessing patient satisfaction with physician home visit programs. Home Health Care Services Quarterly, 19(4), 1-16.

New research establishes importance of specialty care after discharge for an MI. (2003, Apr). Disease Management Advisor, 9(4), 61-3, 50.

Roy, M.J., Herbers, J.E., & Seidman, A., et al. (2003, May). Improving patient satisfaction with the transfer of care. A randomized controlled trial. Journal of General Internal Medicine, 18(5), 364-9.

Van Walraven, C., Mamdani, M., & Fang, J., et al. (2004, Jun). Continuity of care and patient outcomes after hospital discharge. Journal of General Internal Medicine, 19(6), 624-31.

Van Walraven, C., Seth, R., & Austin, P.C., et al. (2002, Mar). Effect of discharge summary availability during post-discharge visits on hospital readmission. Journal of General Internal Medicine, 17(3), 86-92.

Winn, P.A., & Dentino, A.N. (2004 May-Jun). Quality palliative care in long-term care settings. Journal of the American Medical Directors Association, 5(3), 197-206.

Home Care/Supportive Services

Aneshensel, C.S. (2000, May). The transition from home to nursing home: Mortality among people with dementia. Journal of Gerontological Nursing, 27(11), 10-18.

Applebaum, R., Straker, J., & Mehadizadeh, S., et al. (2002, Spring). Using high-intensity care management to integrate acute and long-term care services: Substitute for large scale system reform? Care Management Journals, 3(3), 113-119.

Bellome, J.A., & Bryan, P. (2003, Aug). Setting the standard for community-based care and creating a comprehensive continuum of care. Caring, 22(8), 10-11. Bowles, K.H. (2000, Nov). Vulnerable links in the home care referral process. Caring, 19(11), 34-7.

Bowles, K.H., Foust, J.B., & Naylor, M.D. (2003, Aug). Hospital discharge referral decision making: A multidisciplinary perspective. Applied Nursing Research, 16(3), 134-43.

Bull, M.J., Hansen, H.E., & Gross, C.R. (2000). Differences in family caregiver outcomes by their level of involvement in discharge planning. Applied Nursing Research, 13(2), 76-82.

Bull, M.J., Lou, D., & Maruyama, G.M. (2000, Summer). Measuring continuity of elders' posthospital care. Journal of Nursing Measurement, 8(1), 41-60.

Bull, M.J., Maruyama, G.M., & Luo, D. (1995). Testing a model for posthospital transition of family caregivers for elderly persons. Nursing Research, 44(3), 132-138.

e-Ethics (2003, July). Ethical issues in discharging the frail, elderly patient. http://www.parkridgecenter.org/ethics_july03.html.

Fisher, H.M., & Raphael, T.G. (2003, Feb). Managed long-term care integration through care coordination. Journal of Aging and Health, 15(1), 223-245.

Fortinsky, R.H., Unson, C.G., & Garcia, R.I. (2002, Jun). Helping family caregivers by linking primary care physicians with community-based dementia care services: The Alzheimer's Service Coordination Plan. Dementia, 1(2), 227-240.

Gorshe, N. (2000, Jun). Supporting aging in place and assisted living through home care. Caring, 19(6), 20-22.

Grimmer, K.A., & Moss, J. (2001). The development, validity, and application of a new instrument to assess the quality of discharge planning activities from the community perspective. International Journal of Healthcare, 13(2), 109-116.

Hayley, D.C., Muir, J.C., & Stocking, C., et al. (2001, Nov-Dec). Not ready for hospice: Characteristics of patients in a pre-hospice program. American Journal of Hospice and Palliative Care, 18(6), 377-82.

Laditka, S.B., Jenkins, C.L., & Trevisani, G., et al. (2001). Doctor on the patient's turf: Assessing patient satisfaction with physician home visit programs. Home Health Care Services Quarterly, 19(4), 1-16.

Lawler, K. (2001, Oct). Aging in place: Coordinating housing and health care provision for America's growing elderly population. Harvard University; Cambridge, MA; Washington D.C.: Joint Center for Housing Studies, Graduate School of Design and John F. Kennedy School of Government.

Lee, B. (2001, Fall). Challenges facing case management in a changing social environment. Case Management Journals, 3(1), 20-24.

Luetz, W.N., Greenlick, M.R., & Nonnenkamp, L. (2003). Linking medical care and community services: Practical models for bridging the gap. New York, N.Y.: Springer Pub.

Liu, A.L., & Taylor, D.M. (2002, Dec). Adverse events and complications among patients admitted to hospital in the home directly from the emergency department. Emergency Medicine, 14(4), 400-5.

Magilvy, J.K., & Congdon, J.G. (2000, Sep-Oct). The crisis nature of health care transitions for rural older adults. Public Health Nursing, 17(5), 336-45.

Mollica, R. (2003, Feb). Coordinating services across the continuum of health, housing and supportive services. Journal of Aging and Health, 15(1), 165-188.

Murtaugh, C.M., & Litke, A. (2002, Mar). Transitions through postacute and long-term care settings: Patterns of use and outcomes for a national cohort of elders. Medical Care, 40(3), 227-36.

Naylor, M.D., & Roe-Prior, P. (1999). Transitions between acute and long term care. Advances in Long Term Care. Volume IV. New York: Springer, 1-22.

Porter, E.J. (2001, Fall). An older widow's transition from home care to assisted living. Care Management Journals, 3(1), 25-32.

Roy, C.L., Poon, E.G., & Karson, A.S., et al. (2005, July 19). Patient safety concerns arising from test results that return after hospital discharge. Annals of Internal Medicine, 143(2), 121-128.

Turnbull, G.B. (2002, Dec). Connecting the disconnect between hospital and home. Ostomy Wound Management, 48(12), 14, 16.

United States Commission on Affordable Housing and Health Facility Needs for Seniors in the 21st Century. (2002, June 30). Quiet crisis in America: A report to Congress. Washington, D.C.

Vladeck, F. (2004). Good place to grow old: New York's model for NORC supportive service programs. New York, N.Y.: United Hospital Fund of New York.

Nursing Homes

Aneshensel, C.S. (2000, May). The transition from home to nursing home: Mortality among people with dementia. Journal of Gerontological Nursing, 27(11), 10-18.

Aizen, E., Swartman, R., & Clarfield, A.M. (2001, Oct). Hospitalization of nursing home residents in an acute-care geriatric department: Direct versus emergency room admission. The Israel Medical Association Journal, 3(10), 734-8.

Bellelli, G., Lucchi, E., & Magnifico, F., et al. (2005, Aug). Rehospitalization and transfers to nursing facilities in elderly patients after hip fracture surgery. Journal of the American Geriatric Society, 53(8), 1443-5.

Boockvar, K., Fishman, E., & Kyriacou, C.K., et al. (2004, March 8). Adverse events due to the discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities. Archives of Internal Medicine, 164(5), 545-50.

Cortes, T.A., Wexler, S., & Fitzpatrick, J.J. (2004, Jun). Transition of elderly patients between hospitals and nursing homes. Improving nurse-to-nurse communication. Journal of Gerontological Nursing, 30(6), 10-5.

Crotty, M., Rowett, D., & Spurling, L., et al. (2004, Dec). Does the addition of a pharmacist transition coordinator improve evidence-based medication management and health outcomes in older adults moving from the hospital to a long-term care facility? Results of a randomized, controlled trial. American Journal of Geriatric Pharmacotherapy, 2(4), 257-64.

Gorshe, N. (2000, Jun). Supporting aging in place and assisted living through home care. Caring, 19(6), 20-22.

Hayley, D.C., Muir, J.C., & Stocking, C., et al. (2001, Nov-Dec). Not ready for hospice: Characteristics of patients in a pre-hospice program. American Journal of Hospice and Palliative Care, 18(6), 377-82.

Jackson, B., Swanson, C., & Hicks, L.E., et al. (2000, Jan-Feb). Bridge of continuity from hospital to nursing home - part I: A proactive approach to reduce relocation stress syndrome in the elderly. Continuum Society for Social Work Leadership in Health Care, 20(1), 3-8.

Jackson, B., Swanson, C., & Hicks, L.E., et al. (2000, Jan-Feb). Bridge of continuity from hospital to nursing home - part II: A proactive approach to reduce relocation stress syndrome in the elderly. Continuum Society for Social Work Leadership in Health Care, 20(1), 3-8.

Lahn, M., Friedman, B., & Bijur, P., et al. (2001, Dec). Advance directives in skilled nursing facility residents transferred to emergency departments. Academic Emergency Medicine, 8(12), 1158-62.

Mallick, M.J., & Whipple, T.W. (2000, Mar-Apr). Validity of the nursing diagnosis of relocation stress syndrome. Nursing Research, 49(2), 97-100

McKain, S., Henderson, A., & Kuys, S., et al. (2005, Jul). Exploration of patients' needs for information on arrival at a geriatric and rehabilitation unit. Journal of Clinical Nursing, 14(6), 704-10.

Meehan, T., Robertson, S., & Stedman, T., & et al (2004, Nov-Dec). Outcomes for elderly patients with mental illness following relocation from a stand-alone psychiatric hospital to community-based extended care units. Australian and New Zealand Journal of Psychiatry, 38(11-12), 948-52.

Mirotznik, J., & Kamp, L.L. (2000, Oct). Cognitive status and relocation stress: A test of the vulnerability hypothesis. Gerontologist, 40(5), 531-9.

Mor, V., Papandonatos, G., & Miller, S.C. (2005, Feb). End-of-life hospitalization for African American and non-Latino white nursing home residents: Variation by race and a facility's racial composition. Journal of Palliative Medicine, 8(1), 58-68.

Murtaugh, C.M., & Litke, A. (2002, Mar). Transitions through postacute and long-term care settings: Patterns of use and outcomes for a national cohort of elders. Medical Care, 40(3), 227-36.

Nasraway, S.A., Button, G.J., & Rand, W.M., et al. (2000, Jan). Survivors of catastrophic illness: Outcome after direct transfers from intensive care to extended care facilities. Critical Care Medicine, 28(1), 19-25.

Naylor, M.D., & Brooten, D., & Campbell, R., et al. (1999). Comprehensive follow-up of hospitalized elders. Journal of the American Medical Association, 281(7), 613-620.

Naylor, M.D., & Roe-Prior, P. (1999). Transitions between acute and long term care. Advances in Long Term Care. Volume IV. New York: Springer, 1-22.

Pauls, M.A., Singer, P.A., & Dubinsky, I. (2001, Jul). Communicating advance directives from long-term care facilities to emergency departments. Journal of Emergency Medicine, 21(1), 83-9.

Porter, E.J. (2001, Fall). An older widow's transition from home care to assisted living. Care Management Journals, 3(1), 25-32. Purdy, W. (2002, Nov-Dec). Nursing home to emergency room? The troubling last transfer. Hastings Center Report, 32(6), 46-8.

Saliba, D., Kingston, R., & Buchanan, J., et al. Appropriateness of the decision to transfer nursing facility residents to the hospital. Journal of the American Geriatric Association, 48(2), 154-63.

Terrell, K.M., Brizendine, E.J., & Bean, W.F., et al. (2005, Feb). An extended care facility-to-emergency department transfer form improves communication. Academic Emergency Medicine, 12(2), 114-8.

Winn, P.A., & Dentino, A.N. (2004 May-Jun). Quality palliative care in long-term care settings. Journal of the American Medical Directors Association, 5(3), 197-206.

Hospice and Palliative Care

Beresford, L. (2001). Hospital-hospice partnerships in palliative care: Creating a continuum of service. Alexandria, VA.: National and Palliative Care Organization.

Byock, I.R. (2001, Dec). End-of-life care: A public health crisis and an opportunity for managed care. American Journal of Managed Care, 7(12), 1123-1132.

Hayley, D.C., Muir, J.C., & Stocking, C., et al. (2001, Nov-Dec). Not ready for hospice: Characteristics of patients in a pre-hospice program. American Journal of Hospice and Palliative Care, 18(6), 377-82.

Pekmezaris, R., Breuer, L., & Zaballero, A., et al. (2004, Feb). Predictors of site of death of end-of-life patients: The importance of specificity in advance directives. Journal of Palliative Medicine, 7(1), 9-17.

Sheehan, M. (2004, Nov). Palliative care: Hospice and hospital collaboration. Caring, 23(11), 38-41.

Winn, P.A., & Dentino, A.N. (2004 May-Jun). Quality palliative care in long-term care settings. Journal of the American Medical Directors Association, 5(3), 197-206.

Rural Health Care

Bolda, E.J., & Seavey, J.W. (2001, Dec). Rural long-term care integration: Developing service capacity. Journal of Applied Gerontology, 20(4), 426-457.

Coburn, A.F. (2001, Dec). Models for integrating and managing actue and long-term care services in rural areas. Journal of Applied Gerontology, 20(4), 386-408.

Kuder, L.C., Beaulieu, J., & Rowles, G.D. (2001, Dec). State and local initiatives and research questions for rural long-term care models. Journal of Applied Gerontology, 20(4), 471-479.

Magilvy, J.K., & Congdon, J.G. (2000, Sep-Oct). The crisis nature of health care transitions for rural older adults. Public Health Nursing, 17(5), 336-45.

Mental Health Dementia

Aneshensel, C.S. (2000, May). The transition from home to nursing home: Mortality among people with dementia. Journal of Gerontological Nursing, 27(11), 10-18.

Bartels, S.J. (2004, Dec). Caring for the whole person: Integrated health care for older adults with severe mental illness and medical comorbidity. Journal of the American Geriatric Society, 52(12, Supp.), S2409-S257.

Bartels, S.J. (2003, Sep-Oct). Improving the system of care for older adults with mental illness in the United States. American Journal of Geriatric Psychiatry, 11(5), 486-497.

Fortinsky, R.H., Unson, C.G., & Garcia, R.I. (2002, Jun). Helping family caregivers by linking primary care physicians with community-based dementia care services: The Alzheimer's Service Coordination Plan. Dementia, 1(2), 227-240.

Kettl, P. (2003, Jan). Managing Alzheimer's Disease in the new health care economy. Administration and Policy in Mental Health, 30(3), 267-273.

Laditka, S.B., & Jenkins, C.L. (2000, Nov). Enhancing inter-network cooperation among organizations providing mental health services to older persons. Administration and Policy in Mental Health, 28(2), 75-89.

Meehan, T., Robertson, S., & Stedman, T., & et al (2004, Nov-Dec). Outcomes for elderly patients with mental illness following relocation from a stand-alone psychiatric hospital to community-based extended care units. Australian and New Zealand Journal of Psychiatry, 38(11-12), 948-52.

Mirotznik, J., & Kamp, L.L. (2000, Oct). Cognitive status and relocation stress: A test of the vulnerability hypothesis. Gerontologist, 40(5), 531-9.