Transforming healthcare delivery: The essential role of nurses, administrators, and pharmacists in advancing population health management
Keywords:
Integrated care systems, chronic illness management, socioeconomic determinants of health, nursing, health administration, population health management, health equityAbstract
Background: Population Health Management (PHM) is a transformative approach to improving health outcomes by addressing both clinical and social determinants of health within specific populations. This strategy utilizes advanced technology and data analytics to prioritize prevention, proactive care, and enhanced collaboration across healthcare systems. Despite its potential, the integration of PHM into healthcare delivery remains uneven, requiring further research into its methods, outcomes, and implications, particularly for nursing, health administration, and pharmacy. Aim: This paper critically analyzes the foundational principles, processes, and outcomes of PHM, focusing on its impact on healthcare delivery. It examines the role of social determinants of health in achieving equity in care and explores how nursing, healthcare administration, and pharmacy contribute to optimizing and implementing PHM frameworks. Methods: A thorough literature review was conducted, utilizing peer-reviewed articles and case studies from high-impact publications. This review focused on PHM frameworks, including value-based care models and the Triple Aim, to assess key outcomes, challenges, and enablers of successful PHM implementation within integrated health systems. Results: The research findings indicate that PHM provides several notable benefits, such as reduced hospitalization rates, improved management of chronic diseases, and greater health equity through targeted interventions.
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Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The Triple Aim: Care, health, and cost. Health Affairs, 27(3), 759–769. https://doi.org/10.1377/hlthaff.27.3.759
Kindig, D., & Stoddart, G. (2003). What is population health? American Journal of Public Health, 93(3), 380–383. https://doi.org/10.2105/ajph.93.3.380
Institute for Healthcare Improvement. (2020). Achieving population health goals: Interventions and considerations. Retrieved from https://www.ihi.org
McCarthy, D., & Klein, S. (2010). The Triple Aim framework in action: Case studies. Commonwealth Fund, 102, 1–16.
World Health Organization (WHO). (2020). Noncommunicable diseases: Fact sheet. Retrieved from https://www.who.int
Artiga, S., & Hinton, E. (2018). Beyond health care: The role of social determinants in promoting health and health equity. Kaiser Family Foundation. Retrieved from https://www.kff.org
Bodenheimer, T., & Sinsky, C. (2014). From triple to quadruple aim: Care of the patient requires care of the provider. Annals of Family Medicine, 12(6), 573–576. https://doi.org/10.1370/afm.1713
Bates, D. W., & Sheikh, A. (2018). The future of health information technology in improving population health. BMJ, 363, k5048. https://doi.org/10.1136/bmj.k5048 DOI: https://doi.org/10.1136/bmj.k5048
Khoury, M. J., & Ioannidis, J. P. A. (2014). Big data meets public health. Science, 346(6213), 1054–1055. https://doi.org/10.1126/science.aaa2709
Centers for Medicare & Medicaid Services (CMS). (2020). Value-based programs. Retrieved from https://www.cms.gov
Binagwaho, A., & Mathewos, K. (2020). Lessons from COVID-19: A global perspective on health systems. The Lancet Global Health, 8(10), e1298–e1299. https://doi.org/10.1016/S2214-109X(20)30399-3
Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The Triple Aim: Care, health, and cost. Health Affairs, 27(3), 759–769. https://doi.org/10.1377/hlthaff.27.3.759
Stiefel, M., & Nolan, K. (2012). A guide to measuring the Triple Aim: Population health, experience of care, and per capita cost. IHI Innovation Series White Paper. Retrieved from http://www.ihi.org
Shortell, S. M., Gillies, R. R., & Wu, F. M. (2010). United States innovations in population health management. Journal of Ambulatory Care Management, 33(3), 187–196. https://doi.org/10.1097/JAC.0b013e3181e7e59c
Wagner, E. H., Austin, B. T., & Von Korff, M. (1996). Improving outcomes in chronic illness. The Milbank Quarterly, 74(4), 511–544. https://doi.org/10.2307/3350391
Bodenheimer, T., & Handley, M. A. (2009). Goal-setting for behavior change in primary care: An exploration and status report. Patient Education and Counseling, 76(2), 174–180. https://doi.org/10.1016/j.pec.2009.06.001 DOI: https://doi.org/10.1016/j.pec.2009.06.001
Coleman, K., Austin, B. T., Brach, C., & Wagner, E. H. (2009). Evidence on the Chronic Care Model in the new millennium. Health Affairs, 28(1), 75–85. https://doi.org/10.1377/hlthaff.28.1.75 DOI: https://doi.org/10.1377/hlthaff.28.1.75
Porter, M. E., & Lee, T. H. (2013). The strategy that will fix health care. Harvard Business Review, 91(10), 50–70.
McClellan, M., Kent, J., Beales, S. J., Macdonnell, M., Thoumi, A., Shuttleworth, B., & Cohen, D. (2014). Accountable care around the world: A framework to guide reform strategies. Health Affairs, 33(9), 1507–1515. https://doi.org/10.1377/hlthaff.2014.0371 DOI: https://doi.org/10.1377/hlthaff.2014.0373
Joynt Maddox, K. E., Deardorff, A., & Xing, J. (2019). Acceleration of accountable care organizations to achieve high-value care. JAMA, 321(19), 1875–1876. https://doi.org/10.1001/jama.2019.4144
Bates, D. W., Sheikh, A., & Asch, D. A. (2017). Innovative uses of data for health system performance. BMJ Quality & Safety, 26(6), 459–462. https://doi.org/10.1136/bmjqs-2016-006884
Khoury, M. J., & Ioannidis, J. P. A. (2014). Big data meets public health. Science, 346(6213), 1054–1055. https://doi.org/10.1126/science.aaa2709 DOI: https://doi.org/10.1126/science.aaa2709
23. Zulman, D. M., Pal Chee, C., Ezeji-Okoye, S. C., Shaw, J. G., Holmes, T. H., & Asch, S. M. (2017). Effect of intensive primary care on patient-centered outcomes in patients with high healthcare needs. JAMA Internal Medicine, 177(8), 1022–1030. https://doi.org/10.1001/jamainternmed.2017.0995 DOI: https://doi.org/10.1001/jamainternmed.2016.8021
24. Shrank, W. H., Rogstad, T. L., & Parekh, N. (2019). Waste in the US health care system: Estimated costs and potential for savings. JAMA, 322(15), 1501–1509. https://doi.org/10.1001/jama.2019.13978 DOI: https://doi.org/10.1001/jama.2019.13978
25. Artiga, S., & Hinton, E. (2018). Beyond health care: The role of social determinants in promoting health and health equity. Kaiser Family Foundation. Retrieved from https://www.kff.org
26. Bodenheimer, T., & Sinsky, C. (2014). From triple to quadruple aim: Care of the patient requires care of the provider. Annals of Family Medicine, 12(6), 573–576. https://doi.org/10.1370/afm.1713
27. Buerhaus, P. I., Auerbach, D. I., & Staiger, D. O. (2016). Recent changes in the number of nurses employed and job openings filled in hospitals in the United States. Nursing Economics, 34(3), 123–130.
28. McCarthy, D., & Klein, S. (2010). The Triple Aim framework in action: Case studies. Commonwealth Fund, 102, 1–16.
29. Marmot, M., & Allen, J. (2014). Social determinants of health equity. American Journal of Public Health, 104(S4), S517–S519. https://doi.org/10.2105/AJPH.2014.302200
Braveman, P., & Gottlieb, L. (2014). The social determinants of health: It’s time to consider the causes of the causes. Public Health Reports, 129(S2), 19–31. https://doi.org/10.1177/00333549141291S206 DOI: https://doi.org/10.1177/00333549141291S206
Marmot, M., & Allen, J. J. (2014). Social determinants of health equity. American Journal of Public Health, 104(S4), S517–S519. https://doi.org/10.2105/AJPH.2014.302200
Adler, N. E., & Stead, W. W. (2015). Patients in context—EHR capture of social and behavioral determinants of health. New England Journal of Medicine, 372(8), 698–701. https://doi.org/10.1056/NEJMp1413945 DOI: https://doi.org/10.1056/NEJMp1413945
World Health Organization. (2013). Social determinants of health. Retrieved from https://www.who.int
Artiga, S., & Hinton, E. (2018). Beyond health care: The role of social determinants in promoting health and health equity. Kaiser Family Foundation. Retrieved from https://www.kff.org
Bambra, C., Gibson, M., Sowden, A. J., Wright, K., Whitehead, M., & Petticrew, M. (2010). Tackling the wider social determinants of health and health inequalities: Evidence from systematic reviews. Journal of Epidemiology & Community Health, 64(4), 284–291. https://doi.org/10.1136/jech.2008.082743 DOI: https://doi.org/10.1136/jech.2008.082743
National Association of Community Health Centers. (2016). PRAPARE: Protocol for responding to and assessing patients’ assets, risks, and experiences. Retrieved from http://nachc.org
Garg, A., Boynton-Jarrett, R., & Dworkin, P. H. (2016). Avoiding the unintended consequences of screening for social determinants of health. JAMA, 316(8), 813–814. https://doi.org/10.1001/jama.2016.9282 DOI: https://doi.org/10.1001/jama.2016.9282
Heiman, H. J., & Artiga, S. (2015). Beyond health care: The role of social determinants in promoting health and health equity. Health Affairs. Retrieved from https://www.healthaffairs.org
Manatt Health. (2019). Addressing social determinants of health through Medicaid accountable care organizations. Manatt Health Insights. Retrieved from https://www.manatt.com
Berkowitz, S. A., Hulberg, A. C., Standish, S., Reznor, G., Atlas, S. J., & Wexler, D. J. (2017). Addressing food insecurity in health care settings: A pilot study. Journal of the American Board of Family Medicine, 30(3), 396–404. https://doi.org/10.3122/jabfm.2017.03.160272
Community Solutions. (2019). Built for Zero: Reducing homelessness in America. Retrieved from https://www.community.solutions
DeSalvo, K. B., Wang, Y. C., Harris, A., Auerbach, J., Koo, D., & O'Carroll, P. (2017). Public health 3.0: A call to action for public health to meet the challenges of the 21st century. Preventing Chronic Disease, 14, E78. https://doi.org/10.5888/pcd14.170017 DOI: https://doi.org/10.5888/pcd14.170017
Mikkelsen, L., & Haar, W. (2015). Investing in prevention: Addressing social determinants of health. Health Affairs, 34(5), 758–764. https://doi.org/10.1377/hlthaff.2014.1366
Baer, H. J., Gottlieb, L. M., & Weissman, J. S. (2013). Addressing social determinants of health in a clinical setting. JAMA Internal Medicine, 173(2), 153–155. https://doi.org/10.1001/jamainternmed.2013.124 DOI: https://doi.org/10.1001/jamainternmed.2013.560
Shapiro, J. S., Mostashari, F., Hripcsak, G., Soulakis, N., & Kuperman, G. (2011). Using health information exchange to improve public health. American Journal of Public Health, 101(4), 616–623. https://doi.org/10.2105/AJPH.2008.157362 DOI: https://doi.org/10.2105/AJPH.2008.158980
Vest, J. R., & Gamm, L. D. (2010). Health information exchange: Persistent challenges and new strategies. Journal of the American Medical Informatics Association, 17(3), 288–294. https://doi.org/10.1136/jamia.2010.003673
Adler-Milstein, J., Holmgren, A. J., Kralovec, P., & Worzala, C. (2017). Health information exchange progress and challenges: Evidence from a multi-year survey of US hospitals. Journal of the American Medical Informatics Association, 24(5), 873–879. https://doi.org/10.1093/jamia/ocx029
Kruse, C. S., Mileski, M., & Moreno, J. (2018). Barriers to electronic health record adoption: A systematic literature review. BMJ Open, 8(2), e019263. https://doi.org/10.1136/bmjopen-2017-019263
Gunter, T. D., & Terry, N. P. (2005). The emergence of national electronic health record architectures in the United States and Australia: Models, costs, and questions. Journal of Medical Internet Research, 7(1), e3. https://doi.org/10.2196/jmir.7.1.e3 DOI: https://doi.org/10.2196/jmir.7.1.e3
Jones, S. S., Rudin, R. S., Perry, T., & Shekelle, P. G. (2014). Health information technology: An updated systematic review with a focus on meaningful use. Annals of Internal Medicine, 160(1), 48–54. https://doi.org/10.7326/M13-1531 DOI: https://doi.org/10.7326/M13-1531
Ash, J. S., Kilo, C. M., & Sittig, D. F. (2001). Organizational factors affecting physician use of clinical information technology. Journal of the American Medical Informatics Association, 8(6), 564–570. https://doi.org/10.1136/jamia.2001.0080564
Bates, D. W., Sheikh, A., & Asch, D. A. (2017). Innovative uses of data for health system performance. BMJ Quality & Safety, 26(6), 459–462. https://doi.org/10.1136/bmjqs-2016-006884
Avati, A., Jung, K., Harman, S., Downing, L., Ng, A., & Shah, N. H. (2018). Improving palliative care with deep learning. BMC Medical Informatics and Decision Making, 18(4), 1–11. https://doi.org/10.1186/s12911-018-0648-5 DOI: https://doi.org/10.1186/s12911-018-0677-8
Khairat, S., Marc, D., Crosby, W., & Al Sanousi, A. (2018). Reasons for physicians not adopting clinical decision support systems: Critical analysis. JMIR Medical Informatics, 6(2), e24. https://doi.org/10.2196/medinform.8912 DOI: https://doi.org/10.2196/medinform.8912
Obermeyer, Z., Emanuel, E. J., & Levy, J. H. (2016). Predicting the future—Big data, machine learning, and clinical medicine. The New England Journal of Medicine, 375(13), 1216–1219. https://doi.org/10.1056/NEJMp1606181
Shah, N. H., & Milstein, A. (2017). Bringing machine learning to the bedside. BMJ, 358, j2740. https://doi.org/10.1136/bmj.j2740
Wang, Y., Kung, L. A., & Byrd, T. A. (2018). Big data analytics: Understanding its capabilities and potential benefits for healthcare organizations. Technological Forecasting and Social Change, 126, 3–13. https://doi.org/10.1016/j.techfore.2018.05.018
Jalali, M. S., & Kaiser, J. P. (2018). Cybersecurity in hospitals: A systematic, organizational perspective. Journal of Medical Internet Research, 20(5), e10059. https://doi.org/10.2196/10059 DOI: https://doi.org/10.2196/10059
Chai, S., Bagchi-Sen, S., Morrell, C., Rao, H. R., & Upadhyaya, S. (2011). Internet and data security: Understanding performance and challenges in healthcare organizations. Communications of the Association for Information Systems, 28(1), 25. https://doi.org/10.17705/1cais.02825 DOI: https://doi.org/10.17705/1CAIS.02825
Dolley, S. (2018). Big data’s role in precision public health. Frontiers in Public Health, 6, 68. https://doi.org/10.3389/fpubh.2018.00068 DOI: https://doi.org/10.3389/fpubh.2018.00068
Blumenthal, D., & Tavenner, M. (2010). The “meaningful use” regulation for electronic health records. New England Journal of Medicine, 363(6), 501–504. https://doi.org/10.1056/NEJMp1006114 DOI: https://doi.org/10.1056/NEJMp1006114
Rinner, C., Sauter, S. K., Endel, G., Heinze, G., Thurner, S., & Klimek, P. (2016). Improving the interoperability of health data using openEHR: The SmICS project. BMC Medical Informatics and Decision Making, 16(1), 96. https://doi.org/10.1186/s12911-016-0337-5
Kindig, D., & Stoddart, G. (2003). What is population health? American Journal of Public Health, 93(3), 380–383. https://doi.org/10.2105/ajph.93.3.380
Bodenheimer, T., & Sinsky, C. (2014). From triple to quadruple aim: Care of the patient requires care of the provider. Annals of Family Medicine, 12(6), 573–576. https://doi.org/10.1370/afm.1713
Shortell, S. M., Gillies, R. R., Wu, F. M., Colla, C. H., & Lewis, V. A. (2015). A taxonomy of accountable care organizations for policy and practice. Health Services Research, 50(6), 1469–1486. https://doi.org/10.1111/1475-6773.12307 DOI: https://doi.org/10.1111/1475-6773.12307
Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The Triple Aim: Care, health, and cost. Health Affairs, 27(3), 759–769. https://doi.org/10.1377/hlthaff.27.3.759 DOI: https://doi.org/10.1377/hlthaff.27.3.759
McCarthy, D., & Klein, S. (2010). The Triple Aim framework in action: Case studies. Commonwealth Fund, 102, 1–16.
Grol, R., & Grimshaw, J. (2003). From best evidence to best practice: Effective implementation of change in patients' care. The Lancet, 362(9391), 1225–1230. https://doi.org/10.1016/S0140-6736(03)14546-1 DOI: https://doi.org/10.1016/S0140-6736(03)14546-1
Heiman, H. J., & Artiga, S. (2015). Beyond health care: The role of social determinants in promoting health and health equity. Health Affairs. Retrieved from https://www.healthaffairs.org
Hudson, B., Hunter, D., & Peckham, S. (2019). Policy failure and the policy-implementation gap: Can policy support programs help? Policy Design and Practice, 2(1), 1–14. https://doi.org/10.1080/25741292.2018.1540378 DOI: https://doi.org/10.1080/25741292.2018.1540378
Mikkelsen, L., & Haar, W. (2015). Investing in prevention: Addressing social determinants of health. Health Affairs, 34(5), 758–764. https://doi.org/10.1377/hlthaff.2014.1366
Batalden, P., & Davidoff, F. (2007). What is “quality improvement” and how can it transform healthcare? Quality and Safety in Health Care, 16(1), 2–3. https://doi.org/10.1136/qshc.2006.022046 DOI: https://doi.org/10.1136/qshc.2006.022046
Ryan, A. M., Shortell, S. M., Ramsay, P. P., & Casalino, L. P. (2015). Salary and quality compensation for physician practices participating in accountable care organizations. Annals of Family Medicine, 13(4), 321–324. https://doi.org/10.1370/afm.1805
Porter, M. E., & Lee, T. H. (2013). The strategy that will fix health care. Harvard Business Review, 91(10), 50–70.
Kindig, D., & Stoddart, G. (2003). What is population health? American Journal of Public Health, 93(3), 380–383. https://doi.org/10.2105/ajph.93.3.380
Bodenheimer, T., & Sinsky, C. (2014). From triple to quadruple aim: Care of the patient requires care of the provider. Annals of Family Medicine, 12(6), 573–576. https://doi.org/10.1370/afm.1713 DOI: https://doi.org/10.1370/afm.1713
Joynt Maddox, K. E., Deardorff, A., & Xing, J. (2019). Acceleration of accountable care organizations to achieve high-value care. JAMA, 321(19), 1875–1876. https://doi.org/10.1001/jama.2019.4144
Porter, M. E., & Lee, T. H. (2013). The strategy that will fix health care. Harvard Business Review, 91(10), 50–70.
Heiman, H. J., & Artiga, S. (2015). Beyond health care: The role of social determinants in promoting health and health equity. Health Affairs. Retrieved from https://www.healthaffairs.org
Ware, J. E., & Hays, R. D. (1988). Methods for measuring patient satisfaction with specific medical encounters. Medical Care, 26(4), 393–402. DOI: https://doi.org/10.1097/00005650-198804000-00008
Manary, M. P., Boulding, W., Staelin, R., & Glickman, S. W. (2013). The patient experience and health outcomes. New England Journal of Medicine, 368(3), 201–203. https://doi.org/10.1056/NEJMp1211775 DOI: https://doi.org/10.1056/NEJMp1211775
Street, R. L., Makoul, G., Arora, N. K., & Epstein, R. M. (2009). How does communication heal? Pathways linking clinician-patient communication to health outcomes. Patient Education and Counseling, 74(3), 295–301. https://doi.org/10.1016/j.pec.2008.11.015 DOI: https://doi.org/10.1016/j.pec.2008.11.015
Chen, J., & Mullins, C. D. (2019). Personalized care and the patient-centered outcomes research institute: Ensuring engagement in research and implementation. Journal of Comparative Effectiveness Research, 8(3), 157–160. https://doi.org/10.2217/cer-2018-0114 DOI: https://doi.org/10.2217/cer-2018-0114
Fendrick, A. M., Smith, D. G., & Chernew, M. E. (2001). Applying value-based insurance design to low-value health services. Health Affairs, 39(1), 62–70. https://doi.org/10.1377/hlthaff.2019.00403
Maciosek, M. V., Coffield, A. B., Edwards, N. M., Flottemesch, T. J., Goodman, M. J., & Solberg, L. I. (2006). Priorities among effective clinical preventive services. American Journal of Preventive Medicine, 31(1), 52–61. https://doi.org/10.1016/j.amepre.2006.03.012 DOI: https://doi.org/10.1016/j.amepre.2006.03.012
Vest, J. R., & Gamm, L. D. (2010). Health information exchange: Persistent challenges and new strategies. Journal of the American Medical Informatics Association, 17(3), 288–294. https://doi.org/10.1136/jamia.2010.003673 DOI: https://doi.org/10.1136/jamia.2010.003673
Adler-Milstein, J., Holmgren, A. J., Kralovec, P., & Worzala, C. (2017). Health information exchange progress and challenges: Evidence from a multi-year survey of US hospitals. Journal of the American Medical Informatics Association, 24(5), 873–879. https://doi.org/10.1093/jamia/ocx029 DOI: https://doi.org/10.1093/jamia/ocx080
Obermeyer, Z., Emanuel, E. J., & Levy, J. H. (2016). Predicting the future—Big data, machine learning, and clinical medicine. The New England Journal of Medicine, 375(13), 1216–1219. https://doi.org/10.1056/NEJMp1606181 DOI: https://doi.org/10.1056/NEJMp1606181
Shah, N. H., & Milstein, A. (2017). Bringing machine learning to the bedside. BMJ, 358, j2740. https://doi.org/10.1136/bmj.j2740 DOI: https://doi.org/10.1136/bmj.j2740
Wang, Y., Kung, L. A., & Byrd, T. A. (2018). Big data analytics: Understanding its capabilities and potential benefits for healthcare organizations. Technological Forecasting and Social Change, 126, 3–13. https://doi.org/10.1016/j.techfore.2018.05.018 DOI: https://doi.org/10.1016/j.techfore.2015.12.019
Heiman, H. J., & Artiga, S. (2015). Beyond health care: The role of social determinants in promoting health and health equity. Health Affairs. Retrieved from https://www.healthaffairs.org
Berkowitz, S. A., Hulberg, A. C., Standish, S., Reznor, G., Atlas, S. J., & Wexler, D. J. (2017). Addressing food insecurity in health care settings: A pilot study. Journal of the American Board of Family Medicine, 30(3), 396–404. https://doi.org/10.3122/jabfm.2017.03.160272
Porter, M. E., & Lee, T. H. (2013). The strategy that will fix health care. Harvard Business Review, 91(10), 50–70.
Ryan, A. M., Shortell, S. M., Ramsay, P. P., & Casalino, L. P. (2015). Salary and quality compensation for physician practices participating in accountable care organizations. Annals of Family Medicine, 13(4), 321–324. https://doi.org/10.1370/afm.1805 DOI: https://doi.org/10.1370/afm.1805
Kindig, D., & Stoddart, G. (2003). What is population health? American Journal of Public Health, 93(3), 380–383. https://doi.org/10.2105/ajph.93.3.380 DOI: https://doi.org/10.2105/AJPH.93.3.380
Artiga, S., & Hinton, E. (2018). Beyond health care: The role of social determinants in promoting health and health equity. Kaiser Family Foundation. Retrieved from https://www.kff.org
Marmot, M., & Allen, J. J. (2014). Social determinants of health equity. American Journal of Public Health, 104(S4), S517–S519. https://doi.org/10.2105/AJPH.2014.302200 DOI: https://doi.org/10.2105/AJPH.2014.302200
Coleman, E. A., Parry, C., Chalmers, S., & Min, S. J. (2006). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166(17), 1822–1828. https://doi.org/10.1001/archinte.166.17.1822 DOI: https://doi.org/10.1001/archinte.166.17.1822
Naylor, M. D., Aiken, L. H., Kurtzman, E. T., Olds, D. M., & Hirschman, K. B. (2011). The importance of transitional care in achieving health reform. Health Affairs, 30(4), 746–754. https://doi.org/10.1377/hlthaff.2011.0041 DOI: https://doi.org/10.1377/hlthaff.2011.0041
Funnell, M. M., & Anderson, R. M. (2004). Empowerment and self-management of diabetes. Clinical Diabetes, 22(3), 123–127. https://doi.org/10.2337/diaclin.22.3.123 DOI: https://doi.org/10.2337/diaclin.22.3.123
Bodenheimer, T., Wagner, E. H., & Grumbach, K. (2002). Improving primary care for patients with chronic illness: The Chronic Care Model, part 2. JAMA, 288(15), 1909–1914. https://doi.org/10.1001/jama.288.15.1909 DOI: https://doi.org/10.1001/jama.288.15.1909
Wagner, E. H., Austin, B. T., & Von Korff, M. (1996). Improving outcomes in chronic illness. The Milbank Quarterly, 74(4), 511–544. https://doi.org/10.2307/3350391 DOI: https://doi.org/10.2307/3350391
Norris, S. L., Engelgau, M. M., & Narayan, K. M. V. (2001). Effectiveness of self-management training in type 2 diabetes: A systematic review of randomized controlled trials. Diabetes Care, 24(3), 561–587. https://doi.org/10.2337/diacare.24.3.561 DOI: https://doi.org/10.2337/diacare.24.3.561
Driessen, J., Bonhomme, A., Chang, W., Naylor, M. D., & Haller, K. (2018). Home-based care programs: Benefits and limitations. Home Health Care Management & Practice, 30(4), 183–190. https://doi.org/10.1177/1084822318770623
Kruse, C. S., Karem, P., Shifflett, K., Vegi, L., Ravi, K., & Brooks, M. (2018). Evaluating barriers to adopting telemedicine worldwide: A systematic review. Journal of Telemedicine and Telecare, 24(1), 4–12. https://doi.org/10.1177/1357633X16674087 DOI: https://doi.org/10.1177/1357633X16674087
Sinsky, C. A., & Bodenheimer, T. (2019). Powering-up primary care teams: Advanced team care with in-room support. Annals of Family Medicine, 17(4), 367–371. https://doi.org/10.1370/afm.2422 DOI: https://doi.org/10.1370/afm.2422
Mason, D. J., Dickson, E. L., McLemore, M. R., & Perez, G. A. (2018). Policy and politics in nursing and health care. Elsevier Health Sciences.
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