1. Boult C, Kane RL, Brown R. Managed care of chronically ill older people: The US experience. BMJ. 2000; 321(7267):1011-4.

2. WHO. Innovative care for chronic conditions: building blocks for action. Global report WHO/NMC/CCH. Ginebra: WHO; 2002.

3. Boult C, Kane RL, Pacala JT, Wagner EH. Innovative healthcare for chronically ill older persons: results of a national survey. Am J Managed Care. 1999; 5(9): 1162-1172.

4. Singh D, Ham C. Improving care for people with long-term conditions. A review of UK and international frameworks. University of Birmingham(HSMC); Institute for Innovation and Improvement(NHS); 2006.

5. National Public Health Service for Wales. International Overview of the Evidence on Effective Service Models in Chronic Disease Management. Cardiff: Welsh Assembly Government; 2006.

6. Weiss KB. Managing complexity in chronic care: an overview of the VA state-of-the-art (SOTA) conference. J Gen Intern Med. 2007 Dec;22 (Suppl 3):374-8.

7. Bengoa R, Nuño R (eds). Curar y Cuidar. Innovación en la gestión de enfermedades crónicas: una guía práctica para avanzar. Barcelona: Elsevier-Masson; 2008.

8. Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Quarterly. 1996;74(4):511-544.

9. Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Effective Clin Practice. 1998;1(1):2-4.

10. Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: are they consistent with the literature? Managed Care Quart. 1999;7(3):56-66.

11. Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the Chronic Care Model in the New Millennium. Health Affairs. 2009; 28(1): 75-85.

12. Barr VJ, Robinson S, Marin-Link B, Underhill L, Dotts A, Ravensdale D, Salivaras S. The expanded chronic care model: an integration of concepts and strategies from population health promotion and the chronic care model. Hospital Quarterly. 2003;7(1):73-82.

13. Epping-Jordan JE, Pruitt SD, Bengoa R, Wagner EH. Improving the quality of health care for chronic conditions. Quality and Safety in Health Care. 2004;13(4):299-305.

14. Nuño R. Atención innovadora a las condiciones crónicas: más necesaria que nunca, Revista de Innovación Sanitaria y Atención Integrada. 2009. Disponible en: http://pub.bsalut.net/risai/vol1/iss3/2.

15. Beaglehole RB, Epping-Jordan JE, Patel V, Chopra M, Ebrahim S, Kidd M, Haines A. Improving the prevention and management of chronic disease in low-income and middle-income countries: a priority for primary health care. The Lancet. 2008; 372(9642):940-49.

16. Pearson ML, Wu S, Schaefer J, Bonomi AE, Shortell SM, Mendel PJ, Marsteller JA, Louis TA, Rosen M, Keeler EB. Assessing the implementation of the chronic care model in quality improvement collaboratives. Health Serv Res. 2005; 40(4):978-96.

17. Hroscikoski MC, Solberg LI, Sperl-Hillen JM, Harper PG, McGrail MP, Crabtree BF. Challenges of change: a qualitative study of chronic care model implementation. Ann Fam Med. 2006;4(4):317-26.

18. Russell G, Thille P, Hogg W, Lemelin J. Beyond fighting fires and chasing tails? Chronic illness care plans in Ontario, Canada. Ann Fam Med. 2008;6(2):146-53.

19. Tsai AC, Morton SC, Mangione CM, Keeler EB. A meta-analysis of interventions to improve care for chronic illnesses. Am J Manag Care. 2005;11(8):478-488.

20. Sperl-Hillen JM. Do all components of the chronic care model contribute equally to quality improvement? Joint Commission journal on quality and safety. 2004; 30(6): 303-9.

21. Shojania KG, Ranji SR, McDonald KM, Grimshaw JM, Sundaram V, Rushakoff RJ, Owens DK. Effects of Quality Improvement Strategies for Type 2 Diabetes on Glycemic Control: A Meta-Regression Analysis. Journal of the American Medical Association. 2006: 296(4) 427-440.

22. Parchman ML, Zeber JE, Romero RR, Pugh JA. Risk of coronary artery disease in type 2 diabetes and the delivery of care consistent with the chronic care model in primary care settings: A STARNet study. Med Care. 2007;45(12):1129-1134.

23. Parchman ML, Pugh JA, Wang CP, Romero RL. Glucose control, self-care behaviors, and the presence of the chronic care model in primary care clinics. Diabetes Care. 2007;30(11):2849-54.

24. Parchman M, Kaissi AA. Are elements of the chronic care model associated with cardiovascular risk factor control in type 2 diabetes? Jt Comm J Qual Patient Saf. 2009 Mar;35(3):133-8.

25. Kaissi AA, Parchman M. Organizational factors associated with self-management behaviors in diabetes primary care clinics. Diabetes Educ. 2009 Sep-Oct;35(5):843-50.

26. Wagner EH, Sandhu N, Newton KM, McCulloch DK, Ramsey SD, Grothaus LC . Effect of improved glycemic control on health care costs and utilization. JAMA. 2001; 285(2):182-9.

27. Gilmer TP, O'Connor PJ, Rush WA, Crain AL, Whitebird RR, Hanon AM, Solberg LI. Impact of office systems and improvement strategies on costs of care for adults with diabetes. Diabetes Care. 2006; 29(6):1242-8.

28. Huang ES, Zhang Q, Brown SES, Drum, ML, Meltzer DO, Chin, MH. The cost-effectiveness of improving diabetes care in U.S. federally qualified community health centers. Health Services Research. 2007; 42(6 Pt 1): 2174- 93.

29. Sevick MA, Trauth JM, Ling BS, Anderson RT, Piatt GA, Kilbourne AM, Goodman RM. Patients with Complex Chronic Diseases: perspectives on supporting self-management. J Gen Intern Med. 2007 Dec;22 (Suppl 3):438-44.

30. Tracy CS, Dantas GC, Moineddin R, Upshur REG. The nexus of evidence, context, and patient preferences in primary care: postal survey of Canadian family physicians. BMC Fam Pract. 2003; 4: 13.

31. Tinetti ME, Bogardus ST Jr, Agostini JV. Potential pitfalls of specific disease guidelines for patients with multiple conditions. N Engl J Med. 2004; 351(27):2870-4.

32. Upshur REG, Tracy S. Chronicity and complexity: Is what's good for the diseases always good for the patients? Can Fam Physician. 2008; 54(12): 1655-1658.

33. Boyd CM, Boult C, Shadmi E, et al. Guided care for multi-morbid older adults. Gerontologist. 2007; 47(5):697-704.

34. Boult C, Reider L, Frey K, Leff B, Boyd CM, Wolff JL, Wegener S, Marsteller J, Karm L, Scharfstein D. Early Effects of "Guided Care" on the Quality of Health Care for Multimorbid Older Persons: A Cluster-Randomized Controlled Trial. J Gerontol Med Sci. 2008; 63A(3):321-327.

35. Sylvia M, Griswold M, Dunbar L, Boyd CM, Park M, Boult C. Guided Care: Cost and Utilization Outcomes in a Pilot Study. Dis Manag. 2008; 11(1):29-36.

36. Wolff JL, Rand-Giovannetti E, Palmer S, Wegener S, Reider L, Frey K, Boult C. Caregiving and Chronic Care: The Guided Care Program for Families and Friends. J Gerontol Med Sci. 2009; 64A(7):785-791.

37. Nuño R. Buenas practicas en gestión sanitaria: el caso Kaiser Permanente. Rev Adm Sanit. 2007; 5(2): 283-292.

38. Hutt R, Rosen R, McCauley J. Case-managing long-term conditions. London: King’s Fund 2004.

39. Ham C. Lost in Translation? Health Systems in the US and the UK. Social Policy and Administration. 2005; 39: 192-209.

40. Drennan V, Goodman C. Nurse-led case management for older people with long-term conditions. Br J Community Nurs. 2004; 9(12):527-33.

41. Sylvia ML, Shadmi E, Hsiao CJ, Boyd CM, Schuster AB, Boult C. Clinical features of high-risk older persons identified by predictive modeling. Dis Manag. 2006; 9(1):56-62.

42. Goodwin N, Curry N. Methods for predicting risk of emergency hospitalization. In: 8th INIC Annual Conference. Gothenburg; 7th March 2008.

43. McGraw-Hill Concise Dictionary of Modern Medicine; 2002

44. Ramsey F, Ussery-Hall A, Garcia D, McDonald G, Easton A, Kambon M et al. Prevalence of selected risk behaviors and chronic diseases--Behavioral Risk Factor Surveillance System (BRFSS), 39 steps communities, United States, 2005. MMWR Surveill Summ. 2008 Oct 31;57(11):1-20.

45. Department of Health. Improving chronic disease management. London: The Stationery Office; 2004.

46. Dove HG, Duncan I, Robb A. A prediction model for targeting low-cost, high-risk members of managed care organizations. Am J Manag Care. 2003; 9(5):381-389.

47. Clark CM Jr, Snyder JW, Meek RL, Stutz LM, Parkin CG. A systematic approach to risk stratification and intervention within a managed care environment improves diabetes outcomes and patient satisfaction. Diabetes Care. 2001; 24(6):1079-86.

48. Arshad P, Oxley H, Watts S, Davenport S, Sermin N. Systematic approach to community risk assessment and management. Br J Nurs. 2000;9(4):210-4.

49. Vickers AJ, Kramer BS, Baker SG. Selecting patients for randomized trials: a systematic approach based on risk group. Trials. 2006; 7:30.

50. Bell KM. Physician profiling: 12 critical points. Journal of Ambulatory Care. 1996; 19(1):81-85.

51. Charlson ME, Pompei P, Ales KL, McKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. J Chron Dis. 1987; 40(5): 373-83.

52. Ollero M, Cabrera JM, de Osorno M, de Villar E, García D, Gómez E, et al. Atención al paciente pluripatológico: Proceso Asistencial Integrado. Sevilla: Consejería de Salud; 2002. Disponible en: http://www.juntadeandalucia.es/salud/pro... on 14 June 2009

53. Charlson M, Charlson RE, Briggs W, Holllenberg J. Can disease mangament target patients most likely to generate high cost? The impact of comorbidity. J Gen Intern Med. 2007; 22(4): 464–469.

54. Fussell E. Leaving New Orleans: Social Stratification, Networks, and Hurricane Evacuation. Social Science Research Council 2006; June 11. Disponible en: http://understandingkatrina.ssrc.org/Fus...  on 14/06/2009.

55. Norris SL, Nichols PJ, Caspersen CJ, Glasgow RE, Engelgau MM, Jack L, Isham G, Snyder SR, Carande-Kulis VG, Garfield S, Briss P, McCulloch D. The effectiveness of disease and case management for people with diabetes. A systematic review. Am J Prev Med. 2002;22(4 Suppl):15-38.

56. Gonseth J, Guallar-Castillón P, Banegas JR, Rodríguez-Artalejo F. The effectiveness of disease management programmes in reducing hospital re-admission in older patients with heart failure: a systematic review and meta-analysis of published reports. Eur Heart J. 2004; 25(18):1570-95.

57. Holland R, Battersby J, Harvey I, Lenaghan E, Smith J, Hay L. Systematic review of multidisciplinary interventions in heart failure. Heart. 2005;91(7): 899-906.

58. Evercare: Press releases. Disponible en:  http://evercarehealthplans.com/press_release3.jsp. [Fecha de acceso el 14 Junio de 2009].

59. Kane R, Keckhafer G, Robst J. Evaluation of the Evercare Demonstration Program. Final Report to the Centers for Medicare and Medicaid Services. Minnesota: Division of Health Service Research and Policy, University of Minnesota; 2002.HCFA Contract No. 500-96-0008 Task Order #2

60. Kane RL, Keckhafer G, Flood S, Bershadsky B, Siadaty MS. The effect of Evercare on hospital use. J Am Geriatr Soc. 2003;51(10):1427-34.

61. Implementing the Evercare Program. Interim Report prepared by Evercare on implementation by 9 PCTs. Disponible en: http://www.natpact.nhs.uk/cms/186.php.

62. Gravelle H, Dusheiko M, Sheaff R, Sargent P, Boaden R, Pickard S, Parker S, Roland M. Impact of case management (Evercare) on frail patients: Controlled before and after analysis of quantitative outcome data. BMJ .2007; 334(7583):31–34.

63. Yuen P. BMJ readers should be even more cautious than usual in interpreting the results of the Evercare evaluation. Response to BMJ. Disponible en: http://www.bmj.com/cgi/eletters/334/7583...

64. Sheaff R, Boaden R, Sargent P, Pickard S, Gravelle H, Parker S, Roland M. of case management for frail elderly people: a qualitative study. J Health Serv Res Policy. 2009 Apr;14(2):88-95.

65. Rosen R, Ham C. Integrated Care: Lessons from Evidence and Experience. Birmingham: Nuffield Trust; 2008.

66. Singh D. Transforming chronic care: evidence about improving care for people with long-term conditions. Birmingham: University of Birmingham; 2005.

67. Zwar N, Harris M, Griffiths R, Roland M, Dennis S, Powell Davies G, et al. A systematic review of chronic disease management. UNSW Research Centre for Primary Health Care and Equity, Canberra: Australian Primary Health Care Research Institute (APHCRI); 2006.

68. Ouwens M, Wollersheim H, Hermens R, Hulscher M, Grol R. Integrated care programmes for chronically ill patients: a review of systematic reviews. Int J Qual Health Care. 2005; 17(2):141-6.

69. Busse R, Blümel M, Scheller-Kreinsen D, Zentner A. Managing Chronic Disease in Europe. The Initiative for Sustainable Healthcare financing in Europe; 2009. Disponible en: http://www.sustainhealthcare.org/navigation/CDM_Full_Text.pdf .

70. Nolte E, McKee M (eds). Caring for people with chronic conditions. A health system perspective. Maidenhead: Open University Press. European Observatory on Health Systems and Policies series; 2008.

71. Johnston L, Lardner C, Jepson R. Overview of Evidence Relating to Shifting the Balance of Care: A Contribution to the Knowledge Base. Scottish Government Social Research; 2008.

72. Kreindler S. Lifting the Burden of Chronic Disease. Winnipeg Regional Health Authority; May 2008.

73. Hébert R, Raîche M, Dubois MF, Gueye NR, Dubuc N, Tousignant M. The PRISMA Group. Impact of PRISMA, a Coordination-Type Integrated Service Delivery System for Frail Older People in Quebec (Canada): A Quasi-experimental Study. J Gerontol B Psychol Sci Soc Sci. 2009 May 4. [Epub ahead of print].

74. Oeseburg B, Wynia K, Middel B, Reijneveld SA. Effects of case management for frail older people or those with chronic illness: a systematic review. Nurs Res. 2009;58(3):201-10.

75. Eklund K, Wilhelmson K. Outcomes of coordinated and integrated interventions targeting frail elderly people: a  systematic review of randomised controlled trials. Health Soc Care Community. 2009; 17(5):447-458.

76. MacAdam M. Frameworks of integrated Care for The Elderly: A Systematic review. Ontario: CPRN Research Report; April 2008. Disponible en: http://www.cprn.org/documents/49813_FR.pdf

77. Bodenheimer T, Berry-Millett R. Care management of patients with complex health care needs. Princeton: Robert Wood Johnson Foundation; December 2009. Disponible en: http://www.rwjf.org/pr/product.jsp?id=52372

78. Morgan MW, Zamora NE, Hindmarsh MF. An Inconvenient Truth: A Sustainable Healthcare System Requires Chronic Disease Prevention and Management Transformation. HealthcarePapers. 2007;7(4): 6-23.

79. Mattke S, Seid M, Ma S. Evidence for the effect of disease management: is $1 billion a year a good investment? Am J Manag Care. 2007;13(12):670-6.

80. Rosen R, Ham C. Integrated Care: Lessons from Evidence and Experience. London: Nuffield Trust; 2008.

81. Singh D. Transforming chronic care: evidence about improving care for people with long-term conditions. Birmingham: University of Birmingham; 2005.

82. Zwar N, Harris M, Griffiths R, Roland M, Dennis S, Powell Davies G, et al. A systematic review of chronic disease management. UNSW Research Centre for Primary Health Care and Equity, Canberra: Australian Primary Health Care Research Institute (APHCRI); 2006.

83. Ouwens M, Wollersheim H, Hermens R, Hulscher M, Grol R. Integrated care programmes for chronically ill patients: a review of systematic reviews. Int J Qual Health Care. 2005; 17(2):141-6.

84. Busse R, Blümel M, Scheller-Kreinsen D, Zentner A. Managing Chronic Disease in Europe. The Initiative for Sustainable Healthcare financing in Europe; 2009. Disponible en: http://www.sustainhealthcare.org/navigation/CDM_Full_Text.pdf .

85. Nolte E, McKee M (eds). Caring for people with chronic conditions. A health system perspective. Maidenhead: Open University Press. Brussels: European Observatory on Health Systems and Policies series; 2008.

86. Johnston L, Lardner C, Jepson R. Overview of Evidence Relating to Shifting the Balance of Care: A Contribution to the Knowledge Base. Scottish Government Social Research; 2008.

87.Kreindler S. Lifting the Burden of Chronic Disease. Winnipeg Regional Health Authority; May 2008. Disponible en: http://www.longwoods.com/articles/images/ChronicDiseaseReport.pdf

88. Krumholz HM, Currie PM, Riegel B, et al. A taxonomy for disease management: a scientific statement from the American Heart Association Disease Management Taxonomy Writing Group. Circulation. 2006;114(13):1432-1445.

89. OPIMEC Project. Observatory of Innovative Practices for Complex Chronic Disease Management. Disponible en: http://www.opimec.org/glosario/

90. Medicare Payment Advisory Commission. Report to Congress: Promoting Greater Efficiency in Medicare. Washington: Medicare Payment Advisory Commission; June 2007. Disponible en: http://www.medpac.gov/documents/Jun07_En... 

91. Butcher D, Clarke M. Smart Management: Using Politics in Organizations. New York: Palgrave Macmillan; 2008.

92. Bartlett CA, Ghoshal S. Beyond the Russian Doll Management Model: New Personal Competencies for New Management Roles. In Navigating change: how CEOs, top teams, and boards steer transformation, ed. by Hambrick D C, Nadler D A, Tushman ML. Boston, MA: Harvard Business School Press; 1998.

93. Ovretveit J, Staines A. Sustained Improvement. Findings from an independent case study of the Jonkoping improvement program. Qual Manag Health Care. 2007 Jan-Mar;16(1):68-83.

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