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1 Baicker K, Chandra A, Skinner JS, Wennberg JE. Who you are and where you live: how race and geography affect the

treatment of Medicare beneficiaries. Health Aff (Millwood). 2004;Suppl Web Exclusives:VAR33-44. 2 Modification of “All politics are local” attributed to Tip O’Neill, former Speaker of the US House of Representatives, frequently

heard by this author in various local and national conversations. 3 http://www.communitysolutions.com/assets/2012_Institute_Presentations/caretransitioninterventions051812.pdf

4 http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:h3590enr.txt.pdf

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Baicker%20K%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Chandra%20A%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Skinner%20JS%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Wennberg%20JE%22%5BAuthor%5Djavascript:AL_get(this,%20'jour',%20'Health%20Aff%20(Millwood).');http://www.communitysolutions.com/assets/2012_Institute_Presentations/caretransitioninterventions051812.pdfhttp://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:h3590enr.txt.pdf

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5 http://www.caretransitions.org/

6 http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/CT_Home.cfm

7 http://www.transitionalcare.info/

http://www.caretransitions.org/http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/CT_Home.cfmhttp://www.transitionalcare.info/

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8 Results being prepared for publication 9 Results being prepared for publication 10 http://www.dartmouthatlas.org/downloads/reports/Spending_Brief_022709.pdf 11 Nolan TW. US Health Care Reform by Region. Cambridge, Massachusetts: Institute for Healthcare Improvement; February 2010.

http://www.dartmouthatlas.org/downloads/reports/Spending_Brief_022709.pdf

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http://www.homehealthquality.org/Resources/Success-Stories/Transitional-Care-Coaching-Success-Stories.aspx

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1)

2)

3)

4)

5)

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http://www.cmsa.org/http://www.cmsa.org/portals/0/pdf/CMAG2.pdf

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1)

2)

3)

4)

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http://www.healthsciences.org/http://www.healthsciences.org/

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http://www.homehealthquality.org/Resources/Informational-Resources/Principles-of-MI.aspxhttp://www.homehealthquality.org/Resources/Informational-Resources/Principles-of-MI.aspxhttp://healthsciences.org/information_about_ccp_certification.htmlhttp://www.motivationalinterview.org/http://www.guilford.com/cgi-bin/cartscript.cgi?page=pr/rollnick.htm&dir=pp/AMI_series&cart_id=150127.3641http://www.guilford.com/cgi-bin/cartscript.cgi?page=pr/rollnick.htm&dir=pp/AMI_series&cart_id=150127.3641http://www.guilford.com/cgi-bin/cartscript.cgi?page=pr/rollnick.htm&dir=pp/AMI_series&cart_id=150127.3641

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http://www.nshcoa.com/mailto:info@nshcoa.com

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http://www.homehealthquality.org/hh/campaign/cross1/tools.aspxhttp://www.homehealthquality.org/

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http://www.pentahealth.com/Websites/pentahealth/Images/About/White_Papers/ABridgetotheFuture.pdfhttp:/www.pentahealth.com/http://www.pentahealth.com/

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© 2010- Penta Health (All Rights Reserved)

HOSPITAL

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HOME

HEALTH

PALLIATIVE

CARE HOSPICE

CBTM™: Effective Transitions to

Palliative Care

CBTM™: Effective Transitions to

Palliative Care

© 2010- Penta Health (All Rights Reserved)

MD

SPECIALISTS

WOUND

CLINIC

PCP PHARMACY

CBTM™:

Across Post Acute Settings

CBTM™:

Across Post Acute Settings

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This material was prepared by Quality Insights, the Medicare Quality Innovation Network-Quality Improvement Organization

supporting the Home Health Quality Improvement National Campaign, under contract with the Centers for Medicare & Medicaid

Services (CMS), an agency of the U.S. Department of Health and Human Services. The views presented do not necessarily reflect

CMS policy. Publication number 11SOW-WV-HH-MMD-010517 (pages 13-38)

© 2010- Penta Health (All Rights Reserved)

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ANDable to get

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ComprehendS&S that require

attention AND

whom to contact

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competentAND

have access

Medication

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&persistenceSupport health

literacy for

changes in Rx

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identify change

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Community-Based

Transitions Model™ (CBTM)

Community-Based

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