{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,27]],"date-time":"2026-04-27T19:49:34Z","timestamp":1777319374492,"version":"3.51.4"},"reference-count":30,"publisher":"Springer Science and Business Media LLC","license":[{"start":{"date-parts":[[2026,4,27]],"date-time":"2026-04-27T00:00:00Z","timestamp":1777248000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/www.springernature.com\/gp\/researchers\/text-and-data-mining"},{"start":{"date-parts":[[2026,4,27]],"date-time":"2026-04-27T00:00:00Z","timestamp":1777248000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/www.springernature.com\/gp\/researchers\/text-and-data-mining"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["J GEN INTERN MED"],"DOI":"10.1007\/s11606-026-10382-x","type":"journal-article","created":{"date-parts":[[2026,4,27]],"date-time":"2026-04-27T19:16:26Z","timestamp":1777317386000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Effect of Integrated Care Management Interventions on Post-hospitalization Utilization and Cost Outcomes for Adults with Multiple Chronic Conditions"],"prefix":"10.1007","author":[{"given":"Mary Winger","family":"Knueven","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yushu","family":"Liu","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jane","family":"Kogan","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Dan","family":"Swayze","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Heidi","family":"Stevenson","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sarah","family":"Markwardt","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"James","family":"Schuster","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kelly","family":"Williams","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"297","published-online":{"date-parts":[[2026,4,27]]},"reference":[{"key":"10382_CR1","doi-asserted-by":"publisher","first-page":"E106","DOI":"10.5888\/pcd17.200130","volume":"17","author":"P Boersma","year":"2020","unstructured":"Boersma P, Black LI, Ward BW. Prevalence of Multiple Chronic Conditions Among US Adults, 2018. Prev Chronic Dis. 2020;17:E106. https:\/\/doi.org\/10.5888\/pcd17.200130.","journal-title":"Prev Chronic Dis."},{"issue":"4","key":"10382_CR2","doi-asserted-by":"publisher","first-page":"215","DOI":"10.1002\/nur.21731","volume":"39","author":"S Hewner","year":"2016","unstructured":"Hewner S, Casucci S, Castner J. The Roles of Chronic Disease Complexity, Health System Integration, and Care Management in Post-Discharge Healthcare Utilization in a Low-Income Population. Res Nurs Health. 2016;39(4):215-228. https:\/\/doi.org\/10.1002\/nur.21731.","journal-title":"Res Nurs Health."},{"key":"10382_CR3","unstructured":"CMS Framework for Health Equity | CMS. https:\/\/www.cms.gov\/priorities\/health-equity\/minority-health\/equity-programs\/framework. Accessed 18 Jun 2024."},{"issue":"Suppl 3","key":"10382_CR4","doi-asserted-by":"publisher","first-page":"391","DOI":"10.1007\/s11606-007-0322-1","volume":"22","author":"C Vogeli","year":"2007","unstructured":"Vogeli C, Shields AE, Lee TA, et al. Multiple Chronic Conditions: Prevalence, Health Consequences, and Implications for Quality, Care Management, and Costs. J Gen Intern Med. 2007;22(Suppl 3):391-395. https:\/\/doi.org\/10.1007\/s11606-007-0322-1.","journal-title":"J Gen Intern Med."},{"key":"10382_CR5","unstructured":"Bodenheimer T. Strategies to Reduce Costs and Improve Care for High-Utilizing Medicaid Patients: Reflections on Pioneering Programs."},{"key":"10382_CR6","unstructured":"Mitchell EM. Concentration of Healthcare Expenditures and Selected Characteristics of Persons With High Expenses, U.S. Civilian Noninstitutionalized Population, 2020. In: Statistical Brief (Medical Expenditure Panel Survey (US)). Agency for Healthcare Research and Quality (US); 2001. http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK594344\/. Accessed 24 Nov 2025."},{"key":"10382_CR7","doi-asserted-by":"crossref","unstructured":"Sherman B. Management of Individuals With Multiple Chronic Conditions: A Continuing Challenge. 2021;27. https:\/\/www.ajmc.com\/view\/management-of-individuals-with-multiple-chronic-conditions-a-continuing-challenge. Accessed 20 Jun 2024.","DOI":"10.37765\/ajmc.2021.88665"},{"issue":"6","key":"10382_CR8","doi-asserted-by":"publisher","first-page":"569","DOI":"10.1007\/s40271-023-00645-8","volume":"16","author":"A Grudniewicz","year":"2023","unstructured":"Grudniewicz A, Gray CS, Boeckxstaens P, De Maeseneer J, Mold J. Operationalizing the Chronic Care Model with Goal-Oriented Care. Patient. 2023;16(6):569-578. https:\/\/doi.org\/10.1007\/s40271-023-00645-8.","journal-title":"Patient."},{"issue":"15","key":"10382_CR9","doi-asserted-by":"publisher","first-page":"1909","DOI":"10.1001\/jama.288.15.1909","volume":"288","author":"T Bodenheimer","year":"2002","unstructured":"Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA. 2002;288(15):1909-1914. https:\/\/doi.org\/10.1001\/jama.288.15.1909.","journal-title":"JAMA."},{"issue":"1","key":"10382_CR10","doi-asserted-by":"publisher","first-page":"131","DOI":"10.1377\/hlthaff.2023.01151","volume":"43","author":"A Finkelstein","year":"2024","unstructured":"Finkelstein A, Cantor JC, Gubb J, et al. The Camden Coalition Care Management Program Improved Intermediate Care Coordination: A Randomized Controlled Trial. Health Aff (Millwood). 2024;43(1):131-139. https:\/\/doi.org\/10.1377\/hlthaff.2023.01151.","journal-title":"Health Aff (Millwood)."},{"issue":"S1","key":"10382_CR11","doi-asserted-by":"publisher","first-page":"980","DOI":"10.1111\/1475-6773.13774","volume":"56","author":"LA Savitz","year":"2021","unstructured":"Savitz LA, Bayliss EA. Emerging models of care for individuals with multiple chronic conditions. Health Services Research. 2021;56(S1):980-989. https:\/\/doi.org\/10.1111\/1475-6773.13774.","journal-title":"Health Services Research."},{"issue":"1","key":"10382_CR12","doi-asserted-by":"publisher","first-page":"185","DOI":"10.1007\/s11606-022-07809-6","volume":"38","author":"E Chang","year":"2023","unstructured":"Chang E, Ali R, Seibert J, Berkman ND. Interventions to Improve Outcomes for High-Need, High-Cost Patients: A Systematic Review and Meta-Analysis. J Gen Intern Med. 2023;38(1):185-194. https:\/\/doi.org\/10.1007\/s11606-022-07809-6.","journal-title":"J Gen Intern Med."},{"key":"10382_CR13","doi-asserted-by":"publisher","first-page":"106256","DOI":"10.1016\/j.cct.2020.106256","volume":"101","author":"SM Kearney","year":"2021","unstructured":"Kearney SM, Williams K, Nikolajski C, et al. Stakeholder impact on the implementation of integrated care: Opportunities to consider for patient-centered outcomes research. Contemporary Clinical Trials. 2021;101:106256. https:\/\/doi.org\/10.1016\/j.cct.2020.106256.","journal-title":"Contemporary Clinical Trials."},{"key":"10382_CR14","unstructured":"Williams K, Kogan JN, Markwardt S, et al. Integrated Care for Chronic Conditions: A Randomized Care Management Trial. AJMC. Published online December 3, 2025. https:\/\/www.ajmc.com\/view\/integrated-care-for-chronic-conditions-a-randomized-care-management-trial."},{"issue":"1","key":"10382_CR15","doi-asserted-by":"publisher","first-page":"75","DOI":"10.1377\/hlthaff.28.1.75","volume":"28","author":"K Coleman","year":"2009","unstructured":"Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the Chronic Care Model in the new millennium. Health Aff (Millwood). 2009;28(1):75-85. https:\/\/doi.org\/10.1377\/hlthaff.28.1.75.","journal-title":"Health Aff (Millwood)."},{"issue":"3","key":"10382_CR16","doi-asserted-by":"publisher","first-page":"182","DOI":"10.1016\/j.amjmed.2004.03.018","volume":"117","author":"JJ Ofman","year":"2004","unstructured":"Ofman JJ, Badamgarav E, Henning JM, et al. Does disease management improve clinical and economic outcomes in patients with chronic diseases? A systematic review. Am J Med. 2004;117(3):182-192. https:\/\/doi.org\/10.1016\/j.amjmed.2004.03.018.","journal-title":"A systematic review. Am J Med."},{"key":"10382_CR17","doi-asserted-by":"publisher","unstructured":"Renders CM, Valk GD, Griffin SJ, Wagner E, Eijk JT van, Assendelft WJ. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings - Renders, CM - 2000 | Cochrane Library. https:\/\/www.cochranelibrary.com\/cdsr\/doi\/https:\/\/doi.org\/10.1002\/14651858.CD001481\/full. Accessed 27 Aug 2025.","DOI":"10.1002\/14651858.CD001481\/full"},{"issue":"8","key":"10382_CR18","first-page":"478","volume":"11","author":"AC Tsai","year":"2005","unstructured":"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.","journal-title":"Am J Manag Care."},{"issue":"7370","key":"10382_CR19","doi-asserted-by":"publisher","first-page":"925","DOI":"10.1136\/bmj.325.7370.925","volume":"325","author":"SR Weingarten","year":"2002","unstructured":"Weingarten SR, Henning JM, Badamgarav E, et al. Interventions used in disease management programmes for patients with chronic illness-which ones work? Meta-analysis of published reports. BMJ. 2002;325(7370):925. https:\/\/doi.org\/10.1136\/bmj.325.7370.925.","journal-title":"BMJ."},{"key":"10382_CR20","doi-asserted-by":"publisher","unstructured":"Fortin M, Stewart M. Implementing patient-centred integrated care for multiple chronic conditions: Evidence-informed framework. Canadian Family Physician. 2021;67(4):235\u2013238. https:\/\/doi.org\/10.46747\/cfp.6704235.","DOI":"10.46747\/cfp.6704235"},{"issue":"6","key":"10382_CR21","doi-asserted-by":"publisher","first-page":"315","DOI":"10.1097\/JHQ.0000000000000400","volume":"45","author":"A Lukanski","year":"2023","unstructured":"Lukanski A, Watters S, Bilderback AL, et al. Implementing a Discharge Follow-up Phone Call Program Reduces Readmission Rates in an Integrated Health System. J Healthc Quality (JHQ). 2023;45(6):315. https:\/\/doi.org\/10.1097\/JHQ.0000000000000400.","journal-title":"J Healthc Qual (JHQ)."},{"issue":"1","key":"10382_CR22","doi-asserted-by":"publisher","first-page":"33","DOI":"10.1080\/00031305.1985.10479383","volume":"39","author":"PR Rosenbaum","year":"1985","unstructured":"Rosenbaum PR, Rubin DB. Constructing a Control Group Using Multivariate Matched Sampling Methods That Incorporate the Propensity Score. Am Stat. 1985;39(1):33-38. https:\/\/doi.org\/10.1080\/00031305.1985.10479383.","journal-title":"Am Stat."},{"issue":"3","key":"10382_CR23","doi-asserted-by":"publisher","first-page":"399","DOI":"10.1080\/00273171.2011.568786","volume":"46","author":"PC Austin","year":"2011","unstructured":"Austin PC. An Introduction to Propensity Score Methods for Reducing the Effects of Confounding in Observational Studies. Multivariate Behav Res. 2011;46(3):399-424. https:\/\/doi.org\/10.1080\/00273171.2011.568786.","journal-title":"Multivariate Behav Res."},{"issue":"26","key":"10382_CR24","doi-asserted-by":"publisher","first-page":"2456","DOI":"10.1056\/NEJMp1802313","volume":"378","author":"AJH Kind","year":"2018","unstructured":"Kind AJH, Buckingham WR. Making Neighborhood-Disadvantage Metrics Accessible \u2014 The Neighborhood Atlas. N Engl J Med. 2018;378(26):2456-2458. https:\/\/doi.org\/10.1056\/NEJMp1802313.","journal-title":"N Engl J Med."},{"key":"10382_CR25","doi-asserted-by":"publisher","unstructured":"Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373\u2013383.:https:\/\/doi.org\/10.1016\/0021-9681(87)90171-8.","DOI":"10.1016\/0021-9681(87)90171-8"},{"key":"10382_CR26","unstructured":"Sevak P, Stepanczuk C, Bradley KWV, et al. Effects of a community-based care management model for super-utilizers. The American journal of managed care. Published online November 1, 2018. https:\/\/www.semanticscholar.org\/paper\/Effects-of-a-community-based-care-management-model-Sevak-Stepanczuk\/053382d69107c59ce258fdfc6b90d50c8087b175. Accessed 24 Jun 2024."},{"key":"10382_CR27","doi-asserted-by":"publisher","unstructured":"Powers BW, Modarai F, Palakodeti S, et al. Impact of complex care management on spending and utilization for high-need, high-cost Medicaid patients. Am J Manag Care. 2020;26(2):e57-e63. https:\/\/doi.org\/10.37765\/ajmc.2020.42402.","DOI":"10.37765\/ajmc.2020.42402"},{"key":"10382_CR28","unstructured":"Evaluation of Medicare Care Management for High Cost Beneficiaries (CMHCB) Demonstration: The Health Buddy\u00ae Consortium (HBC) Revised Final Report."},{"issue":"1","key":"10382_CR29","doi-asserted-by":"publisher","first-page":"131","DOI":"10.1377\/hlthaff.2023.01151","volume":"43","author":"A Finkelstein","year":"2024","unstructured":"Finkelstein A, Cantor JC, Gubb J, et al. The Camden Coalition Care Management Program Improved Intermediate Care Coordination: A Randomized Controlled Trial. Health Aff (Millwood). 2024;43(1):131-139. https:\/\/doi.org\/10.1377\/hlthaff.2023.01151.","journal-title":"Health Aff (Millwood)."},{"key":"10382_CR30","doi-asserted-by":"publisher","unstructured":"Wiest D, Yang Q, Kuruna T, Asiedu-Frimpong M. Dosage and outcomes in a complex care intervention. Am J Manag Care. 2023;29(6):293\u2013298. https:\/\/doi.org\/10.37765\/ajmc.2023.89370.","DOI":"10.37765\/ajmc.2023.89370"}],"container-title":["Journal of General Internal Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s11606-026-10382-x.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s11606-026-10382-x","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s11606-026-10382-x.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,27]],"date-time":"2026-04-27T19:16:32Z","timestamp":1777317392000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s11606-026-10382-x"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,27]]},"references-count":30,"alternative-id":["10382"],"URL":"https:\/\/doi.org\/10.1007\/s11606-026-10382-x","relation":{},"ISSN":["0884-8734","1525-1497"],"issn-type":[{"value":"0884-8734","type":"print"},{"value":"1525-1497","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,27]]},"assertion":[{"value":"14 January 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"19 March 2026","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"27 April 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Not applicable.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethical Approval"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent to Participate"}},{"value":"Not applicable.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent to Publish"}},{"value":"All authors are or were employees of UPMC Health Plan or the UPMC Center for High-Value Health Care.","order":5,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of interest"}},{"value":"All statements in this report, including its findings and conclusions, are solely those of the authors and do not necessarily represent the views of PCORI or its Board of Governors or Methodology Committee.","order":6,"name":"Ethics","group":{"name":"EthicsHeading","label":"Disclaimer"}}]}}