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- Setting value-based payment goals—HHS efforts to improve U.S. health care.N Engl J Med. 2015; 372: 897-899
The Lewin Group. CMS Bundled Payments for Care Improvement (BPCI) initiative models 2-4: Year 1 evaluation & monitoring annual report. https://innovation.cms.gov/Files/reports/BPCI-EvalRpt1.pdf. Accessed July 5, 2017.
Department of Health and Human Services. Centers for Medicare & Medicaid Services. Federal Register. Medicare Program; Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services; Final Rule. https://www.gpo.gov/fdsys/pkg/FR-2015-11-24/pdf/2015-29438.pdf. Accessed July 5, 2017.
Department of Health and Human Services. Federal Register. Medicare Program; Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR); Proposed Rule. https://www.gpo.gov/fdsys/pkg/FR-2016-08-02/pdf/2016-17733.pdf. Accessed December 16, 2017.
Medicare Payment Advisory Commission. A data book: Health care spending and the Medicare program. http://medpac.gov/documents/data-book/june-2016-data-book-health-care-spending-and-the-medicare-program.pdf?sfvrsn=0. Published June 2016. Accessed July 20, 2016.
- Mortality, hospitalizations, and expenditures for the Medicare population aged 65 years or older, 1999-2013.JAMA. 2015; 314: 355-365
- Comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after hip fracture repair.Arch Phys Med Rehabil. 2014; 95: 209-217
- Are we asking the right question about postacute settings of care?.Arch Phys Med Rehabil. 2014; 95: 218-221
Centers for Medicare & Medicaid Services. Bundled Payments for Care Improvement (BPCI) initiative: General information. https://innovation.cms.gov/initiatives/bundled-payments/. Accessed March 15, 2017.
Medicare Payment Advisory Commission. Report to the Congress: Medicare and health care delivery systems. http://www.medpac.gov/docs/default-source/reports/jun17_reporttocongress_sec.pdf. Published June 2017. Accessed July 1, 2017.
- Effect of nosocomial bloodstream infections on mortality, length of stay, and hospital costs in older adults.J Am Geriatr Soc. 2014; 62: 306-311
- The contribution of immobility risk factors to the incidence of venous thrombosis in an older population.J Thromb Haemost. 2014; 12: 290-296
- Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: Increased vulnerability with age.J Am Geriatr Soc. 2003; 51: 451-458
- Early hospital readmission is a predictor of one-year mortality in community-dwelling older Medicare beneficiaries.J Gen Intern Med. 2012; 27: 1467-1474
Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation. 2016 procedure-specific readmission measure updates and specifications report, hospital-level 30-day risk standardized readmission measures, elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA)—Version 5.0. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Measure-Methodology.html. Accessed July 18, 2017.
- Early hospital readmission of nursing home residents and community-dwelling elderly adults discharged from the geriatrics service of an urban teaching hospital: Patterns and risk factors.J Am Geriatr Soc. 2015; 63: 548-552
- Trajectories over the first year of long-term care nursing home residence.J Am Med Dir Assoc. 2018; 19: 333-341
- Is nursing home residence an independent predictor of recurrent hospitalization in older adults?.J Am Med Dir Assoc. 2013; 14: 706-707
Centers for Medicare & Medicaid Services. The Inpatient Rehabilitation Facility–Patient Assessment Instrument (IRF-PAI) training manual. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/IRFPAI.html. Accessed June 16, 2016.
Centers for Medicare & Medicaid Services. Long-term care facility resident assessment instrument 3.0 user's manual. Version 1.13. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/MDS-30-RAI-Manual-V113.pdf. Published October 2015. Accessed August 8, 2017.
Medicare Payment Advisory Commission (MedPAC). Medicare post-acute care reforms. http://medpac.gov/docs/default-source/congressional-testimony/testimony-medicare-post-acute-care-reforms-energy-and-commerce-.pdf?sfvrsn=0. Published April 2016. Accessed July 3, 2017.
Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation. 2016 all-cause hospital-wide measure updates and specifications report: Hospital-level 30-day Risk-standardized Readmission Measure. Version 5.0; https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Measure-Methodology.html. Accessed August 10, 2017.
Centers for Medicare & Medicaid Services. 2014 model software/ICD-9-CM mappings. Version 22 CMS-HCC risk-adjustment model. https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors.html. Accessed November 11, 2015.
Pope GC, Kautter J, Ingber MJ, et al. Evaluation of the CMS-HCC risk adjustment model. Final report. https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Evaluation_Risk_Adj_Model_2011.pdf. Published 2011. Accessed December 19, 2016.
Improving Medicare Post-Acute Care Transformation Act of 2014, PL 113–185. https://www.govtrack.us/congress/bills/113/hr4994. Accessed September 1, 2016.
- What are the rates and causes of hospital readmission after total knee arthroplasty?.Clin Orthop Relat Res. 2014; 472: 181-187
- Causes and frequency of unplanned hospital readmission after total hip arthroplasty.Clin Orthop Relat Res. 2014; 472: 464-470
- Association of rehabilitation intensity for stroke and risk of hospital readmission.Phys Ther. 2015; 95: 1660-1667
- Reducing readmissions after stroke with a structured nurse practitioner/registered nurse transitional stroke program.Stroke. 2016; 47: 1599-1604
- Physician assistant home visit program to reduce hospital readmissions.J Thorac Cardiovasc Surg. 2013; 145 (233; discussion 232–223): 225-231
- A reengineered hospital discharge program to decrease rehospitalization: A randomized trial.Ann Intern Med. 2009; 150: 178-187
- Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: A randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program.J Am Geriatr Soc. 2009; 57: 395-402
- Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial.JAMA. 1999; 281: 613-620
- Project ReEngineered Discharge (RED) lowers hospital readmissions of patients discharged from a skilled nursing facility.J Am Med Dir Assoc. 2013; 14: 736-740
- Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia.JAMA. 2013; 309: 355-363
- Nationwide estimates of 30-day readmission in patients with ischemic stroke.Stroke. 2017; 48: 1386-1388
- Hospital, patient, and clinical factors influence 30- and 90-day readmission after primary total hip arthroplasty.J Arthroplasty. 2016; 31: 2130-2138
- Which hospital and clinical factors drive 30- and 90-day readmission after TKA?.J Arthroplasty. 2016; 31: 2099-2107
- Rehospitalizations among patients in the Medicare fee-for-service program.N Engl J Med. 2009; 360: 1418-1428
- The next generation of episode-based payments.JAMA. 2017; 317: 2371-2372
The authors declare no conflicts of interest.