|
[1]
|
Marengoni, A., Angleman, S., Melis, R., Mangialasche, F., Karp, A., Garmen, A., Meinow, B. and Fratiglioni, L. (2011) Aging with multimorbidity: A systematic review of the literature. Ageing Research Reviews, 10, 430-439.
doi:10.1016/j.arr.2011.03.003
|
|
[2]
|
Nardi, R., Scanelli, G., Corrao, S., Iori, I., Mathieu, G. and Amatrian R.C. (2007) Co-morbidity does not reflect complexity in internal medicine patients. European Journal of Internal Medicine, 18, 359-368.
doi:10.1016/j.ejim.2007.05.002
|
|
[3]
|
Reed, J., Cook, G., Childs, S. and McCormack, B. (2005) A literature review to explore integrated care for older people. International Journal of Integrated Care, 5.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=16773170
|
|
[4]
|
Coleman, E.A. (2003) 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, 549-555.
doi:10.1046/j.1532-5415.2003.51185.x
|
|
[5]
|
Condelius, A., Edberg, A.K., Jakobsson, U. and Hallberg, I.R. (2008) Hospital admissions among people 65+ related to multimorbidity, municipal and outpatient care. Archives of Gerontology and Geriatrics, 46, 41-55.
doi:10.1016/j.archger.2007.02.005
|
|
[6]
|
Vogeli, C., Shields, A.E., Lee, T.A., Gibson, T.B., Marder, W.D., Weiss, K.B. and Blumenthal, D. (2007) Multiple chronic conditions: Prevalence, health consequences, and implications for quality, care management, and costs. Journal of General Internal Medicine, 22, 391-395.
doi:10.1007/s11606-007-0322-1
|
|
[7]
|
Gray, L.K., Smyth, K.A., Palmer, R.M., Zhu, X. and Callahan, J.M. (2002) Heterogeneity in older people: Examining physiologic failure, age, and comorbidity. Journal of the American Geriatrics Society, 50, 1955-1961.
doi:10.1046/j.1532-5415.2002.50606.x
|
|
[8]
|
Chong, C.P. and Street, P.R. (2008) Pneumonia in the elderly: A review of the epidemiology, pathogenesis, microbiology, and clinical features. Southern Medical Journal, 101, 1141-1145.
doi:10.1097/SMJ.0b013e318181d5b5
|
|
[9]
|
Cerejeira, J. and Mukaetova-Ladinska, E.B. (2011) A clinical update on delirium: From early recognition to effective management. Nursing Research and Practice, 2011. doi:10.1155/2011/875196
|
|
[10]
|
Ornstein, K., Smith, K.L., Foer, D.H., Lopez-Cantor, M.T. and Soriano, T. (2011) To the hospital and back home again: A nurse practitioner-based transitional care program for hospitalized homebound people. Journal of the American Geriatrics Society, 59, 544-551.
doi:10.1111/j.1532-5415.2010.03308.x
|
|
[11]
|
Boling, P.A. (2009) Care transitions and home health care. Clinics in Geriatric Medicine, 25, 135-148.
doi:10.1016/j.cger.2008.11.005
|
|
[12]
|
Kripalani, S., Jackson, A.T., Schnipper, J.L. and Coleman, E.A. (2007) Promoting effective transitions of care at hospital discharge: A review of key issues for hospitalists. Journal of Hospital Medicine, 2, 314-323.
doi:10.1002/jhm.228
|
|
[13]
|
Coleman, E.A., Min, S.J., Chomiak, A. and Kramer, A.M. (2004) Posthospital care transitions: Patterns, complications, and risk identification. Health Services Research, 39, 1449-1466. doi:10.1111/j.1475-6773.2004.00298.x
|
|
[14]
|
Garasen, H. and Johnsen, R. (2007) The quality of communication about older patients between hospital physicians and general practitioners: A panel study assessment. BMC Health Services Research, 7, 133.
doi:10.1186/1472-6963-7-133
|
|
[15]
|
Brown, E.L., Raue, P.J., Mlodzianowski, A.E., Meyers, B.S., Greenberg, R.L. and Bruce, M.L. (2006) Transition to home care: Quality of mental health, pharmacy, and medical history information. The International Journal of Psychiatry Medicine, 36, 339-349.
doi:10.2190/6N5P-5CXH-L750-A8HV
|
|
[16]
|
Boockvar, K.S., Fridman, B. and Marturano, C. (2005) Ineffective communication of mental status information during care transfer of older adults. Journal of General Internal Medicine, 20, 1146-1150.
doi:10.1111/j.1525-1497.2005.00262.x
|
|
[17]
|
Cwinn, M.A., Forster, A.J., Cwinn, A.A., Hebert, G., Calder, L. and Stiell, I.G. (2009) Prevalence of information gaps for seniors transferred from nursing homes to the emergency department. Canadian Journal of Emergency Medicine, 11, 462-471.
|
|
[18]
|
Carlsson, E., Ehnfors, M., Eldh, A.C. and Ehrenberg, A. (2012) Accuracy and continuity in discharge information for patients with eating difficulties after stroke. Journal of Clinical Nursing, 21, 21-31.
doi:10.1111/j.1365-2702.2010.03648.x
|
|
[19]
|
Coleman, E.A., Smith, J.D., Raha, D. and Min, S.-J. (2005) Posthospital medication discrepancies: Prevalence and contributing factors. Archives of Internal Medicine, 165, 1842-1847. doi:10.1001/archinte.165.16.1842
|
|
[20]
|
Glintborg, B., Andersen, S.E. and Dalhoff, K. (2007) Insufficient communication about medication use at the interface between hospital and primary care. Quality & Safety in Health Care, 16, 34-39.
doi:10.1136/qshc.2006.019828
|
|
[21]
|
Mesteig, M., Helbostad, J.L., Sletvold, O., Rosstad, T. and Saltvedt, I. (2010) Unwanted incidents during transition of geriatric patients from hospital to home: A prospective observational study. BMC Health Services Research, 10, 1. doi:10.1186/1472-6963-10-1
|
|
[22]
|
Helleso, R., Lorensen, M. and Sorensen, L. (2004) Challenging the information gap—The patients transfer from hospital to home health care. International Journal of Medical Informatics, 73, 569-580.
doi:10.1016/j.ijmedinf.2004.04.009
|
|
[23]
|
Anderson, M.A., Helms, L.B., Black, S. and Myers, D.K. (2000) A rural perspective on home care communication about elderly patients after hospital discharge. Western Journal of Nursing Research, 22, 225-243.
doi:10.1177/019394590002200208
|
|
[24]
|
Waibel, S., Henao, D., Aller, M.-B., Vargas, I. and Vázquez, M.-L. (2012) What do we know about patients’ perceptions of continuity of care? A meta-synthesis of qualitative studies. International Journal of Quality in Health Care, 24, 39-48. doi:10.1093/intqhc/mzr068
|
|
[25]
|
Bodenheimer, T. (2008) Coordinating care—A perilous journey through the health care system. New England Journal of Medicine, 358, 1064-1071.
doi:10.1056/NEJMhpr0706165
|
|
[26]
|
Mur-Veeman, I., Van Raak, A. and Paulus, A. (2008) Comparing integrated care policy in Europe: Does policy matter? Health Policy, 85, 172-183.
doi:10.1016/j.healthpol.2007.07.008
|
|
[27]
|
Schoen, C., Osborn, R., Squires, D., Doty, M.M., Pierson, R. and Applebaum, S. (2011) New 2011 survey of patients with complex care needs in eleven countries finds that care is often poorly coordinated. Health Affairs, 30, 2437-2448. doi:10.1377/hlthaff.2011.0923
|
|
[28]
|
Van Servellen, G., Fongwa, M. and D’Errico, E.M. (2006) Continuity of care and quality care outcomes for people experiencing chronic conditions: A literature review. Nursing Health Science, 8, 185-195.
doi:10.1111/j.1442-2018.2006.00278.x
|
|
[29]
|
Saultz, J.W. and Lochner, J. (2005) Interpersonal continuity of care and care outcomes: A critical review. The Annals of Family Medicine, 3, 159-166.
doi:10.1370/afm.285
|
|
[30]
|
Van Walraven, C., Oake, N., Jennings, A. and Forster, A.J. (2010) The association between continuity of care and outcomes: A systematic and critical review. Journal of Evaluation in Clinical Practice, 16, 947-956.
doi:10.1111/j.1365-2753.2009.01235.x.
|
|
[31]
|
Hadjistavropoulos, H.D., Garratt, S., Janzen, J.A., Bourgault-Fagnou, M.D. and Spice, K. (2009) Development and evaluation of a continuity of care checklist for improving orthopaedic patient discharge from hospital. Journal of Orthopaedic Nursing, 13, 183-193.
doi:10.1016/j.joon.2009.05.006
|
|
[32]
|
Cabana, M.D. and Jee, S.H. (2004) Does continuity of care improve patient outcomes? The Journal of Family Practice, 53, 974-980.
|
|
[33]
|
Worrall, G. and Knight, J. (2006) Continuity of care for older patients in family practice: How important is it? Canadian Family Physician, 52, 754-755.
|
|
[34]
|
Parker, G., Corden, A. and Heaton, J. (2011) Experiences of and influences on continuity of care for service users and carers: Synthesis of evidence from a research programme. Health & Social Care in the Community, 19, 576-601. doi:10.1111/j.1365-2524.2011.01001.x
|
|
[35]
|
Heaton, J., Corden, A. and Parker, G. (2012) “Continuity of care”: A critical interpretive synthesis of how the concept was elaborated by a national research programme. International Journal of Integrated Care, 12.
http://www.ijic.org/index.php/ijic/article/view/794
|
|
[36]
|
Haggerty, J.L., Reid, R.J., Freeman, G.K., Starfield, B.H., Adair, C.E. and McKendry, R. (2003) Continuity of care: A multidisciplinary review. British Medical Journal, 327, 1219-1221. doi:10.1136/bmj.327.7425.1219
|
|
[37]
|
Freeman, G.K., Woloshynowych, M., Baker, R., Boulton, M., Guthrie, B., Car, J., Haggerty, J. and Tarrant, C. (2007) Continuity of care 2006: What have we learned since 2000 and what are policy imperatives now? Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R & D (NCCSDO), Imperial College London, London.
|
|
[38]
|
Norwegian Ministry of Health and Care Services (2008) Stortingsmelding nr. 47 (2008-2009), Samhandlingsreformen. Rett behandling—p? rett sted—til rett tid (The Coordination Reform. Proper treatment—At the right place and right time. Report No. 47 (2008-2009) to the Storting) [in Norwegian]. Norwegian Ministry of Health and Care Services, Oslo.
|
|
[39]
|
Norwegian Ministry of Health and Care Services (2011) Nasjonal helseog omsorgsplan (2011-2015) [National health and care plan (2011-2015)] [in Norwegian]. Norwegian Ministry of Health and Care Services, Oslo.
|
|
[40]
|
Rom?ren, T.I., Torjesen, D.O. and Landmark, B. (2011) Promoting coordination in Norwegian health care. International Journal of Integrated Care, 11.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=22128282
|
|
[41]
|
Norwegian Ministry of Health and Care Services (1999) Lov om helsepersonell av 2.juli 1999 nr 64. Helsepersonelloven (Act of 2 July 1999 No. 64 relating to health personnel etc. The health personnel act) (in Norwegian). Norwegian Ministry of Health and Care Services, Oslo.
|
|
[42]
|
Norwegian Ministry of Health and Care Services (2000) Forskrift om pasientjournal (The Norwegian patient record regulation) (in Norwegian). Norwegian Ministry of Health and Care Services, Oslo.
|
|
[43]
|
The Norwegian Nursing Organisation (NSF) (2007) Dokumentasjon av sykepleie i elektronisk pasientjournal (Documenting nursing care in an electronic patient record) (In Norwegian). The Norwegian Nursing Organisation (NSF), Oslo.
|
|
[44]
|
Bach, G. and KITH (2003) Kravspesifikasjon for elektronisk dokumentasjon av sykepleie (Requirements specification for electronic documentation of nursing. National standard) (in Norwegian). KITH Report R 12/03 Norwegian Centre for Informatics in Health and Social Care, Oslo.
http://www.kith.no/upload/1101/R12-03DokumentasjonSykepleie-rev1_1-NasjonalStandard.pdf
|
|
[45]
|
Ehrenberg, A., Ehnfors, M. and Thorell-Ekstrand, I. (1996) Nursing documentation in patient records: Experience of the use of the VIPS model. Journal of Advanced Nursing, 24, 853-867. doi:10.1046/j.1365-2648.1996.26325.x
|
|
[46]
|
Ehnfors, M., Thorell-Ekstrand, I. and Ehrenberg, A. (1991) Towards basic nursing information in patient records. V?rd i Norden, 11, 12-31.
|
|
[47]
|
Ehrenberg, A., Ehnfors, M. and Ekman, I. (2004) Older patients with chronic heart failure within Swedish community health care: A record review of nursing assessments and interventions. Journal of Clinical Nursing, 13, 90-96. doi:10.1046/j.1365-2702.2003.00837.x
|
|
[48]
|
T?rnvall, E., Wilhelmsson, S. and Wahren, L.K. (2004) Electronic nursing documentation in primary health care. Scandinavian Journal of Caring Science, 18, 310-317.
doi:10.1111/j.1471-6712.2004.00282.x
|
|
[49]
|
Ehrenberg, A. and Birgersson, C. (2003) Nursing documentation of leg ulcers: Adherence to clinical guidelines in a Swedish primary health care district. Scandinavian Journal of Caring Science, 17, 278-284.
doi:10.1046/j.1471-6712.2003.00231.x
|
|
[50]
|
Rykkje, L. (2009) Implementing Electronic Patient Record and VIPS in medical hospital wards: Evaluating change in quantity and quality of nursing documentation by using the audit instrument Cat-ch-Ing. V?rd i Norden, 29, 9-13
|
|
[51]
|
H?yrinen, K., Lammintakanen, J. and Saranto, K. (2010) Evaluation of electronic nursing documentation—Nursing process model and standardized terminologies as keys to visible and transparent nursing. International Journal of Medical Informatics, 79, 554-564.
doi:10.1016/j.ijmedinf.2010.05.002
|
|
[52]
|
Gjevjon, E.R. and Helleso, R. (2010) The quality of home care nurses’ documentation in new electronic patient records. Journal of Clinical Nursing, 19, 100-108.
doi:10.1111/j.1365-2702.2009.02953.x
|
|
[53]
|
K?rkk?inen, O., Bondas, T. and Eriksson, K. (2005) Documentation of individualized patient care: A qualitative metasynthesis. Nursing Ethics, 12, 123-132.
doi:10.1191/0969733005ne769oa
|
|
[54]
|
Hyde, A., Treacy, M.P., Scott, P.A., Butler, M., Drennan, J., Irving, K., Byrne, A., MacNeela, P. and Hanrahan, M. (2005) Modes of rationality in nursing documentation: Biology, biography and the “voice of nursing”. Nursing Inquiry, 12, 66-77.
doi:10.1111/j.1440-1800.2005.00260.x
|
|
[55]
|
Gunhardsson, I., Svensson, A. and Berter?, C. (2008) Documentation in palliative care: Nursing documentation in a palliative care unit—A pilot study. The American Journal of Hospice & Palliative Care, 25, 45-51.
doi:10.1177/1049909107307381
|
|
[56]
|
Helles?, R. (2006) Information handling in the nursing discharge note. Journal of Clinical Nursing, 15, 11-21.
doi:10.1111/j.1365-2702.2005.01235.x
|
|
[57]
|
World Medical Association (2008) World Medical Association Declaration of Helsinki. Ethical principles for medical research involving human subjects.
|
|
[58]
|
Isola, A., Backman, K., Voutilainen, P. and Rautsiala, T. (2008) Quality of institutional care of older people as evaluated by nursing staff. Journal of Clinical Nursing, 17, 2480-2489. doi:10.1111/j.1365-2702.2007.01951.x
|
|
[59]
|
Foss, C. and Sundby, J. (2003) The construction of the gendered patient: Hospital staff’s attitudes to female and male patients. Patient Education and Counseling, 49, 45-52. doi:10.1016/S0738-3991(02)00039-3
|
|
[60]
|
Norwegian Directorate of Health (2007) Respekt og kvalitet: Rapport om styrking av spesialisthelsetjenester for eldre (Respect and quality: Report on strengthening health services for the elderly) (in Norwegian). Norwegian Directorate of Health, Oslo.
|
|
[61]
|
Coleman, E.A. and Boult, C. (2003) Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society, 51, 556-557. doi:10.1046/j.1532-5415.2003.51186.x
|
|
[62]
|
Bo, M., Martini, B., Ruatta, C., Massaia, M., Ricauda, N.A., Varetto, A., Astengo, M. and Torta, R. (2009) Geriatric ward hospitalization reduced incidence delirium among older medical inpatients. American Journal of Geriatric Psychiatry, 17, 760-768.
doi:10.1097/JGP.0b013e3181a315d5
|
|
[63]
|
Xyrichis, A. and Lowton, K. (2008) What fosters or prevents interprofessional teamworking in primary and community care? A literature review. International Journal of Nursing Studies, 45, 140-153.
doi:10.1016/j.ijnurstu.2007.01.015
|
|
[64]
|
Geriatrics Interdisciplinary Advisory Group (2006) Interdisciplinary care for older adults with complex needs: American Geriatrics Society position statement. Journal of American Geriatric Society, 54, 849-852.
doi:10.1111/j.1532-5415.2006.00707.x
|
|
[65]
|
Ellis, G., Whitehead, M.A., Robinson, D., O’Neill, D. and Langhorne, P. (2011) Comprehensive geriatric assessment for older adults admitted to hospital: Meta-analysis of randomised controlled trials. British Medical Journal, 343, d6553. doi:10.1136/bmj.d6553
|
|
[66]
|
Grav, S., Hellzèn, O., Romild, U. and Stordal, E. (2012) Association between social support and depression in the general population: the HUNT study, a cross-sectional survey. Journal of Clinical Nursing, 21, 111-120.
doi:10.1111/j.1365-2702.2011.03868.x
|
|
[67]
|
Jellinger, K.A. and Attems, J. (2010) Prevalence of dementia disorders in the oldest-old: An autopsy study. Acta Neuropathologica, 119, 421-433.
doi:10.1007/s00401-010-0654-5
|