Naylor, M. D., D. A. Brooten, R. L. Campbell, G. Maislin, K. M. McCauley, and J. S. Schwartz. 2004. Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. Journal of the American Geriatrics Society 52(5):675–684.

Naylor, M. D., D. Brooten, R. Campbell, B. S. Jacobsen, M. D. Mezey, M. V. Pauly, and J. S. Schwartz. 1999. Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized controlled trial. Journal of the American Medical Association 281(7):613–620.

Peikes, D., A. Chen, J. Schore, and R. Brown. 2009. Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. Journal of the American Medical Association 301(6):603–618.

Poissant, L., J. Pereira, R. Tamblyn, and Y. Kawasumi. 2005. The impact of electronic health records on time efficiency of physicians and nurses: A systematic review. Journal of the American Medical Informatics Association 12(5):505–516.

Rittenhouse, D. R., S. M. Shortell, and E. S. Fisher. 2009. Primary care and accountable care: Two essential elements of delivery-system reform. New England Journal of Medicine 361(24):2301–2303.

Sibbald, B., J. Shen, and A. McBride. 2004. Changing the skill mix of the health care workforce. Journal of Health Services Research and Policy 9(Suppl 1):S128–S138.

Sochalski, J., T. Jaarsma, H. M. Krumholz, A. Laramee, J. J. V. McMurray, M. D. Naylor, M. W. Rich, B. Riegel, and S. Stewart. 2009. What works in chronic care management? The case of heart failure. Health Affairs 28(1):179–189.

Starfield, B., and L. Shi. 2004. The medical home, access to care, and insurance: A review of evidence. Pediatrics 113(5):1493–14998.

Steiner, B. D., A. C. Denham, E. Ashkin, W. P. Newton, T. Wroth, and L. A. Dobson. 2008. Community Care of North Carolina: Improving care through community health networks. Annals of Family Medicine 6(4):361–367.

Sylvia, M. L., M. Griswold, L. Dunbar, C. Boyd, M. Park, and C. Boult. 2008. Guided care: Cost and utilization outcomes in a pilot study. Disease Management 11(1):29–36.

UCSF (University of California, San Francisco), School of Nursing and CHWS (Center for California Health Workforce Studies). 2007. California Board of Registered Nursing 2006 Survey of Registered Nurses. http://www.rn.ca.gov/pdfs/forms/survey2006.pdf (accessed February 25, 2010).

U.S. Department of Health and Human Services, Health Resources and Services Administration. 2010. The registered nurse population: Initial findings from the March 2008 National Sample Survey of Registered Nurses. Rockville, MD: U.S. Department of Health and Human Services.

U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions. 2006. Findings from the March 2004 National Sample Survey of Registered Nurses. Rockville, MD: U.S. Department of Health and Human Services.

Wagner, E. H., B. T. Austin, and M. Von Korff. 1996. Organizing care for patients with chronic illness. Milbank Quarterly 74(4):511–554.