Kleinman A. The illness narratives: suffering, healing, and the human condition. New York: Basic; 1988. p. xviii. 284 p.
Google Scholar
Fleming ST. Primary care, avoidable hospitalization, and outcomes of care: a literature review and methodological approach. Med Care Res Rev. 1995;52(1):88–108.
PubMed
CAS
CrossRef
Google Scholar
Reschovsky JD, et al. Following the money: factors associated with the cost of treating high-cost Medicare beneficiaries. Health Serv Res. 2011;46(4):997–1021.
PubMed
CrossRef
Google Scholar
CARDI: Centre for Ageing Research and Development in Ireland. Stocktake of Ageing Public Policy Initiatives in Ireland, North and South. 2008. Cited 12/9/11.
Google Scholar
Moloney ED, Bennett K, Silke B. Factors influencing the costs of emergency medical admissions to an Irish teaching hospital. Eur J Health Econ. 2006;7(2):123–8.
PubMed
CrossRef
Google Scholar
Crimmins EM, Hayward MD, Saito Y. Changing mortality and morbidity rates and the health status and life expectancy of the older population. Demography. 1994;31(1):159–76.
PubMed
CAS
CrossRef
Google Scholar
Royal College of Physicians of Ireland, et al. Community medical services for the older person. In: Report of the National Acute Medicine Programme; 2011.
Google Scholar
U.S. Agency for Healthcare Research and Quality. AHRQ quality indicators – guide to prevention quality indicators: hospital admissions for ambulatory care sensitive conditions. 2007.
Google Scholar
Vest J, et al. Determinants of preventable readmissions in the United States: a systematic review. Implement Sci. 2010;5(1):88.
PubMed
CrossRef
Google Scholar
Agency for Healthcare Research and Quality. Chronic care and disease management improves health, reduces costs for patients with multiple chronic conditions in an integrated health system. Department of Health and Human Services, Editor 2009: United States. http://innovations.ahrq.gov/content.aspx?id=1696.
Jimenez-Puente A, et al. Readmission rate as an indicator of hospital performance: the case of Spain. Int J Technol Assess Health Care. 2004;20(3):385–91.
PubMed
CrossRef
Google Scholar
van Walraven C, et al. Proportion of hospital readmissions deemed avoidable: a systematic review. Can Med Assoc J. 2011;183(7):E391–402.
CrossRef
Google Scholar
Naylor MD. Transitional care for older adults: a cost-effective model. LDI Issue Brief. 2004;9(6):1–4.
PubMed
Google Scholar
Condelius A, Hallberg I, Jakobsson U. Hospital and outpatient clinic utilization among older people in the 3-5 years following the initiation of continuing care: a longitudinal cohort study. BMC Health Serv Res. 2011;11(1):136.
PubMed
CrossRef
Google Scholar
Martin M, Hin PY, O’Neill D. Acute medical take or subacute-on-chronic medical take? Ir Med J. 2004; 97(7):212–4.
PubMed
CAS
Google Scholar
Baer RB, Pasternack JS, Zwemer Jr FL. Recently discharged inpatients as a source of emergency department overcrowding. Acad Emerg Med. 2001;8(11):1091–4.
PubMed
CAS
CrossRef
Google Scholar
Pines JM, et al. Postdischarge adverse events for 1-day hospital admissions in older adults admitted from the emergency department. Ann Emerg Med. 2010;56(3):253–7.
PubMed
CrossRef
Google Scholar
Brunjes GB. The search for meaning in the face of death. J Health Care Chaplain. 1987;1(1):63–9.
PubMed
CAS
CrossRef
Google Scholar
Barnard A, Hollingum C, Hartfiel B. Going on a journey: understanding palliative care nursing. Int J Palliat Nurs. 2006;12(1):6–12.
PubMed
Google Scholar
Allaudeen N, et al. Redefining readmission risk factors for general medicine patients. J Hosp Med. 2011; 6(2):54–60.
PubMed
CrossRef
Google Scholar
Wallmann R, et al. Prediction of 30-day cardiac-related-emergency-readmissions using simple administrative hospital data. Int J Cardiol. 20 July 2011 (10.1016/j.ijcard.2011.06.119).
Google Scholar
Courtney MD, et al. Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial. J Eval Clin Pract. 2012;18(1):128–34.
PubMed
CrossRef
Google Scholar
Parry C, et al. Further application of the care transitions intervention: results of a randomized controlled trial conducted in a fee-for-service setting. Home Health Care Serv Q. 2009;28(2–3):84–99.
PubMed
CrossRef
Google Scholar
Bittencourt RJ, Hortale VA. Interventions to solve overcrowding in hospital emergency services: a systematic review. Cad Saude Publica. 2009;25(7):1439–54.
PubMed
CrossRef
Google Scholar
Purdy S. Avoiding hospital admissions.What does the research evidence say? London: The King’s Fund; 2010.
Google Scholar
Crane S, et al. Use of an electronic administrative database to identify older community dwelling adults at high-risk for hospitalization or emergency department visits: the elders risk assessment index. BMC Health Serv Res. 2010;10(1):338.
PubMed
CrossRef
Google Scholar
Spencer J, et al. Functional outcomes and daily life activities of African-American elders after hospitalization. Am J Occup Ther. 2002;56(2):149–59.
PubMed
CrossRef
Google Scholar
Rea H, et al. Integrated systems to improve care for very high intensity users of hospital emergency department and for long-term conditions in the community. N Z Med J. 2010;123(1320):76–85.
PubMed
Google Scholar
Armstrong CD, et al. Home-based intermediate care program vs hospitalization: cost comparison study. Can Fam Physician. 2008;54(1):66–73.
PubMed
Google Scholar
Basu A, Brinson D. The effectiveness of interventions for reducing ambulatory sensitive hospitalisations: a systematic review. In: Health Services Advisory Committee Technical Report, Canterbury, New Zealand; 2008. p. 245.
Google Scholar
Kronman AC, et al. Can primary care visits reduce hospital utilization among Medicare beneficiaries at the end of life? J Gen Intern Med. 2008;23(9): 1330–5.
PubMed
CrossRef
Google Scholar
Linertová R, et al. Interventions to reduce hospital readmissions in the elderly: in-hospital or home care. A systematic review. J Eval Clin Pract. 2011;17(6): 1167–75.
PubMed
CrossRef
Google Scholar
Jordon M, et al. Implications of complex adaptive systems theory for interpreting research about health care organizations. Forum Syst Complex Health Care J Eval Clin Pract. 2010;16(1):228–31.
Google Scholar
van Kerkhoff L, Szlezak NA. Knowledge Systems for Sustainable Development Special Feature Sackler Colloquium: The role of innovative global institutions in linking knowledge and action. Proc Natl Acad Sci USA. 2010. Epub 2010/03/03.
Google Scholar
Glass DJ, Arnold SE. Some evolutionary perspectives on Alzheimer’s disease pathogenesis and pathology. Alzheimers Dement. 2012;8(4):343–51.
PubMed
CAS
CrossRef
Google Scholar
Gluckman PD, Hanson MA. Living with the past: evolution, development, and patterns of disease. Science. 2004;305(5691):1733–6.
PubMed
CAS
CrossRef
Google Scholar
Weber BH. Extending and expanding the Darwinian synthesis: the role of complex systems dynamics. Stud Hist Philos Sci C Stud Hist Philos Biol Biomed Sci. 2011;42(1):75–81.
Google Scholar
Shanahan MJ, Hofer SM. Molecular genetics, aging, and well-being: sensitive period, accumulation, and pathway models. In: Binstock RH, George LK, editors. Handbook of aging and the social sciences. 7th ed. San Diego, CA: Academic; 2011. p. 135–47.
CrossRef
Google Scholar
Khushf G. Health as intra-systemic integrity: rethinking the foundations of systems biology and nanomedicine. Perspect Biol Med. 2008;51(3):432–49.
PubMed
CrossRef
Google Scholar
Van Wave TW, Scutchfield FD, Honore PA. Recent advances in public health systems research in the United States. Annu Rev Public Health. 2010;31: 283–95.
PubMed
CrossRef
Google Scholar
Lunney J, et al. Patterns of functional decline at the end of life. J Am Med Assoc. 2003;289:2387–92.
CrossRef
Google Scholar
Gill TM, et al. Trajectories of disability in the last year of life. N Engl J Med. 2010;362(13):1173–80.
PubMed
CAS
CrossRef
Google Scholar
Goldberger AL, et al. Fractal dynamics in physiology: alterations with disease and aging. Proc Natl Acad Sci USA. 2002;99 Suppl 1:2466–72.
PubMed
CrossRef
Google Scholar
Eisenberg DTA. An evolutionary review of human telomere biology: the thrifty telomere hypothesis and notes on potential adaptive paternal effects. Am J Hum Biol. 2011;23(2):149–67.
PubMed
CrossRef
Google Scholar
Zhu H, Belcher M, van der Harst P. Healthy aging and disease: role for telomere biology? Clin Sci. 2011;120(10):427–40.
PubMed
CrossRef
Google Scholar
Glover J, et al. Atlas of avoidable hospitalisations in Australia: ambulatory care-sensitive conditions. Canberra: AIHW; 2007.
Google Scholar
Glouberman S. The grey zones of birth and death. J Eval Clin Pract. 2011;17(2):394–9.
PubMed
CrossRef
Google Scholar
Cole A. Proportion of people dying in hospital is falling. BMJ 2010;341:c4722.
Google Scholar
Gruneir A, et al. Where people die: a multilevel approach to understanding influences on site of death in America. Med Care Res Rev. 2007;64(4):351–78.
PubMed
CrossRef
Google Scholar
Kardamanidis K, et al. Hospital costs of older people in New South Wales in the last year of life. Med J Aust. 2007;187(7):383–6.
PubMed
Google Scholar
Ahearn DJ, et al. Improving end of life care for nursing home residents: an analysis of hospital mortality and readmission rates. Postgrad Med J. 2010;86(1013):131–5.
PubMed
CAS
CrossRef
Google Scholar
Murtagh FEM, et al. End of life trajectories across conditions. BMJ. 2011;342:397–8.
CrossRef
Google Scholar
Zaninotto P, Falaschetti E, Sacker A. Age trajectories of quality of life among older adults: results from the English Longitudinal Study of Ageing. Qual Life Res. 2009;18(10):1301–9.
PubMed
CrossRef
Google Scholar
Visser G, et al. The end of life: informal care for dying older people and its relationship to place of death. Palliat Med. 2004;18(5):468–77.
PubMed
CAS
CrossRef
Google Scholar
Niederman MS, Berger JT. The delivery of futile care is harmful to other patients. Crit Care Med. 2010;38(10 Suppl):S518–22.
PubMed
CrossRef
Google Scholar
Wilson DM, et al. Age-based differences in care setting transitions over the last year of life. Curr Gerontol Geriatr Res. 2011;2011:101276.
PubMed
Google Scholar
Martin CM. Distortions, belief and sense making in complex adaptive systems for health. J Eval Clin Pract. 2011;17(2):387–8.
PubMed
CrossRef
Google Scholar
Yam CH, et al. Avoidable readmission in Hong Kong – system, clinician, patient or social factor? BMC Health Serv Res. 2010;10:311.
PubMed
CrossRef
Google Scholar
Walsh B, Roberts H, Nicholls P. Features and outcomes of unplanned hospital admissions of older people due to ill-defined (R-coded) conditions: retrospective analysis of hospital admissions data in England. BMC Geriatr. 2011;11(1):62.
PubMed
CrossRef
Google Scholar
Condelius A, et al. Hospital admissions among people 65+ related to multimorbidity, municipal and outpatient care. Arch Gerontol Geriatr. 2008;46(1):41–55.
PubMed
CrossRef
Google Scholar
Asarnow JR, Jaycox LH, Anderson M. Depression among youth in primary care models for delivering mental health services. Child Adolesc Psychiatr Clin N Am. 2002;11(3):477–97, viii.
Google Scholar
Laniece I, et al. Incidence and main factors associated with early unplanned hospital readmission among French medical inpatients aged 75 and over admitted through emergency units. Age Ageing. 2008;37(4):416–22.
PubMed
CrossRef
Google Scholar
Bayliss EA, Ellis JL, Steiner JF. Seniors’ self-reported multimorbidity captured biopsychosocial factors not incorporated into two other data-based morbidity measures. J Clin Epidemiol. 2009;62(5):550–7.e1.
PubMed
CrossRef
Google Scholar
Martin CM, Vogel C, Grady D, Zarabzadeh A, Hederman L, Kellett J, et al. Implementation of complex adaptive chronic care: the Patient Journey Record system (PaJR). J Eval Clin Pract. 2012. Epub 2012/07/24.
Google Scholar
Norman CD. Health promotion as a systems science and practice. J Eval Clin Pract. 2009;15(5):868–72.
PubMed
CrossRef
Google Scholar
Watt G, O’Donnell C, Sridharan S. Building on Julian Tudor Hart’s example of anticipatory care. Prim Health Care Res Dev. 2011;12(1):3–10.
PubMed
CrossRef
Google Scholar
Kellett J. Hospital medicine (Part 2): what would improve acute hospital care? Eur J Intern Med. 2009;20(5):465–9.
PubMed
CrossRef
Google Scholar
Naylor MD, et al. Translating research into practice: transitional care for older adults. J Eval Clin Pract. 2009;15(6):1164–70.
PubMed
CrossRef
Google Scholar
Clarke M, Shah A, Sharma U. Systematic review of studies on telemonitoring of patients with congestive heart failure: a meta-analysis. J Telemed Telecare. 2011;17(1):7–14.
PubMed
CrossRef
Google Scholar
McLean S, et al. Telehealthcare for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2011;(7):CD007718.
Google Scholar
Tan HM, et al. GP and nurses’ perceptions of how after hours care for people receiving palliative care at home could be improved: a mixed methods study. BMC Palliat Care. 2009;8:13.
PubMed
CrossRef
Google Scholar
McEvoy P, Escott D, Bee P. Case management for high-intensity service users: towards a relational approach to care co-ordination. Health Soc Care Community. 2011;19(1):60–9.
PubMed
CrossRef
Google Scholar
Lunney JR, et al. Patterns of functional decline at the end of life. JAMA. 2003;289(18):2387–92.
PubMed
CrossRef
Google Scholar
Jylha M, Volpato S, Guralnik J. Self-rated health showed a graded association with frequently used biomarkers in a large population sample. J Clin Epidemiol. 2006;59:465–71.
PubMed
CrossRef
Google Scholar
Nielsen AB, et al. The impact of changes in self-rated general health on 28-year mortality among middle-aged Danes. Scand J Prim Health Care. 2009;27(3):160–6. 1 p following 166.
PubMed
CrossRef
Google Scholar
DeSalvo KB, et al. Health care expenditure prediction with a single item, self-rated health measure. Med Care. 2009;47(4):440–7.
PubMed
CrossRef
Google Scholar
Lawton J. Lay experiences of health and illness: past research and future agendas. Sociol Health Illn. 2003;25(3):23–40.
PubMed
CrossRef
Google Scholar
Rockwood K. What would make a definition of frailty successful? Age Ageing. 2005;34(5):432–4.
PubMed
CrossRef
Google Scholar
Nesse RE, et al. Framing change for high-value healthcare systems. J Healthc Qual. 2010;32(1):23–8.
PubMed
CrossRef
Google Scholar
Hammond RA. Complex systems modeling for obesity research. Prev Chronic Dis. 2009;6(3):A97.
PubMed
Google Scholar
Beautement P, Broenner C. Complexity demystified: a guide for practitioners. Axminster, Devon: Triarchy; 2011. p. 268 p.
Google Scholar
Harquail CV, Wilcox King A. Construing organizational identity: the role of embodied cognition. Organ Stud. 2010;31(12):1619–48.
CrossRef
Google Scholar
Stange KC, Ferrer RL. The paradox of primary care. Ann Fam Med. 2009;7(4):293–9.
PubMed
CrossRef
Google Scholar
Zoloth-Dorfman L, Rubin S. The patient as commodity: managed care and the question of ethics. J Clin Ethics. 1995;6(4):339–57.
PubMed
CAS
Google Scholar
Kurtz C, Snowden D. The new dynamics of strategy: sense-making in a complex and complicated world. IBM Syst J. 2003;42(3):462–83.
CrossRef
Google Scholar
Silva SA, Charon R, Wyer PC. The marriage of evidence and narrative: scientific nurturance within clinical practice. J Eval Clin Pract. 2011;17(4):585–93.
PubMed
CrossRef
Google Scholar
Lakoff G, Johnson M. Philosophy in the flesh: the embodied mind and its challenge to Western thought. New York: Basic; 1999. p. xiv. 624 p.
Google Scholar
Nelson B. A field guide to embodied cognition. 2008. http://corporature.wordpress.com/2008/12/28/a-field-guide-to-embodied-cognition/. Cited 12 Jan 2012.
King’s Fund. Predictive Risk Project: Literature review. NHS Modernisation Agency, New York University, Health Dialog. 2005. http://www.kingsfund.org.uk/current_projects/predicting_and_reducing_readmission_to_hospital/#context. Cited 2 Sept 2011.
Boult C, Pacala JT, Boult LB. Targeting elders for geriatric evaluation and management: reliability, validity, and practicality of a questionnaire. Aging (Milano). 1995;7(3):159–64.
CAS
Google Scholar
Lyon D, et al. Predicting the likelihood of emergency admission to hospital of older people: development and validation of the Emergency Admission Risk Likelihood Index (EARLI). Fam Pract. 2007;24(2):158–67.
PubMed
CrossRef
Google Scholar
Lindquist LA, Baker DW. Understanding preventable hospital readmissions: masqueraders, markers, and true causal factors. J Hosp Med. 2011;6(2):51–3.
PubMed
CrossRef
Google Scholar
Roland M, et al. Follow up of people aged 65 and over with a history of emergency admissions: analysis of routine admission data. BMJ. 2005;330:289–92.
PubMed
CrossRef
Google Scholar
Sidorov J, Shull R. “My patients are sicker:” using the Pra risk survey for case finding and examining primary care site utilization patterns in a medicare-risk MCO. Am J Manag Care. 2002;8(6):569–75.
PubMed
Google Scholar
Martin C. Complex adaptive chronic care - typologies of patient journey: a case study. J Eval Clin Pract. 2011;17(3):1–5.
CrossRef
Google Scholar
Murphy SME, Castro HK, Sylvia M. Predictive modeling in practice: improving the participant identification process for care management programs using condition-specific cut points. Popul Health Manag. 2011;14(4):205–10.
PubMed
CrossRef
Google Scholar
Obenshain MK. Application of data mining techniques to healthcare data. Infect Control Hosp Epidemiol. 2004;25(8):690–5.
PubMed
CrossRef
Google Scholar
Diehr P, et al. Patterns of self-rated health in older adults before and after sentinel health events. J Am Geriatr Soc. 2001;49(1):36–44.
PubMed
CAS
CrossRef
Google Scholar
Gravelle H, et al. Impact of case management (Evercare) on frail elderly patients: controlled before and after analysis of quantitative outcome data. BMJ. 2007;334:31–4.
PubMed
CrossRef
Google Scholar
Snowden DJ, Boone ME. A leader’s framework for decision making. A leader’s framework for decision making. Harv Bus Rev. 2007;85(11):68–76, 149.
Google Scholar
Biddiss E, Brownsell S, Hawley MS. Predicting need for intervention in individuals with congestive heart failure using a home-based telecare system. J Telemed Telecare. 2009;15(5):226–31.
PubMed
CrossRef
Google Scholar
Gruneir A, Silver MJ, Rochon PA. Emergency department use by older adults: a literature review on trends, appropriateness, and consequences of unmet health care needs. Med Care Res Rev. 2011;68(2):131–55.
PubMed
CrossRef
Google Scholar
Martin CM, Grady D, Deaconking S, McMahon C, Zarabzadeh A, O’Shea B. Complex adaptive chronic care - typologies of patient journey: a case study. J Eval Clin Pract. 2011;17(3):520–4.
Google Scholar
Huang T, et al. A systems-oriented multilevel framework for addressing obesity in the 21st century. Prev Chronic Dis. 2009;6(3):A82.
PubMed
Google Scholar
Horvitz E. From data to predictions and decisions: enabling evidence-based healthcare. Series on data analytics 1. Computing Community Consortium; 2010.
Google Scholar
Bayati M, et al. Predictive models and policies for minimizing rehospitalizations for congestive heart failure. 2010. in press.
Google Scholar
Jylhä M. What is self-rated health and why does it predict mortality? Towards a unified conceptual model. Soc Sci Med. 2009;69(3):307–16.
PubMed
CrossRef
Google Scholar
Lewis S. Seeking a new biomedical model. How evolutionary biology may contribute. J Eval Clin Pract. 2009;15(4):745–8.
PubMed
CrossRef
Google Scholar
Sturmberg J, Martin C, Moes M. Health at the centre of health systems reform – how philosophy can inform policy. Perspect Biol Med. 2010;53(3):341–56.
PubMed
CrossRef
Google Scholar
Quinlan JR. C4.5: Programs for machine learning. Burlington, MA: Morgan Kaufmann, Elsevier; 1993.
Google Scholar
Kerr WT, Lau EP et al. The future of medical diagnostics: large digitized databases. Yale J Biol Med. 2012;85(3):363–377.
Google Scholar
Sheskin D. Handbook of Parametric and Nonparametric Statistical Procedures. 3 ed. Baton Rouge, Florida: CRC Press; 2004.
Google Scholar
Vapnik VN. Statistical Learning Theory. New York: John Wiley and Sons, Inc; 1998.
Google Scholar
Manning C, Raghavan P, Schütze H. Introduction to Information Retrieval. Cambridge: Cambridge University Press; 2008.
Google Scholar
Mitchell T. Machine Learning. Liu C, editor. USA: McGraw Hill; 1997.
Google Scholar
Jain A, Murty M, Flynn P. Data Clustering. A Review. http://eprints.iisc.ernet.in/273/1/p264-jain.pdf1997. (Accessed 7/10/12).
Google Scholar
Duntemann G. Principal Components Analysis. Newbury Park, California: Sage Publications Inc; 1989.
Google Scholar
Cryer J, Chan K. Time Series Analysis with Applications in R New York: Springer 2008.
Google Scholar
Witten I, Frank E, Hall M. Data mining: practical machine learning tools and techniques, The Morgan Kaufmann series in data management systems. 3rd ed. Burlington, MA: Morgan Kaufmann, Elsevier; 2011.
Google Scholar
Cheshire J, Ziebland S. Narrative as a resource in accounts of the experience of illness. In: Thornborrow J, Coates J, editors. The sociolinguistics of narrative. Amsterdam: John Benjamins; 2005.
Google Scholar
Martin CM, et al. Patient Journey Record Systems (PaJR): the development of a conceptual framework for a patient journey system. In: Biswas R, Martin CM, editors. User-driven healthcare and narrative medicine: utilizing collaborative social networks and technologies. Hershey, PA: IGI; 2010. p. 75–92.
CrossRef
Google Scholar
Boyd CM, et al. Guided care for multimorbid older adults. Gerontologist. 2007;47(5):697–704.
Google Scholar
Murray SA, et al. Archetypal trajectories of social, psychological, and spiritual wellbeing and distress in family care givers of patients with lung cancer: secondary analysis of serial qualitative interviews. BMJ. 2010;340:c2581.
CrossRef
Google Scholar