Care coordination in primary care: views of clinicians and clinic leaders. 

Journal of Nursing Care Quality. 2025

Care coordination: how is it implemented and is it different if a social worker is on the team?. 

Journal of the American Board of Family Medicine. 2025

Uncovering four types of care coordination in primary care. 

Journal of the American Board of Family Medicine. 2025

Patient experiences and perceptions of care coordination in primary care. 

Journal of Nursing Care Quality. 2024

The role of care coordination: a qualitative study of care coordinator perceptions. 

Journal of Nursing Care Quality. 2024

Care coordination in primary care: mapping the territory. 

American Journal of Managed Care. 2023

Is there room for individual patient-specified preferences in the patient-reported outcome measurement revolution?. 

Journal of patient-centered research and reviews. 2023

The impact of COVID-19 on patients receiving care coordination in primary care: a qualitative study. 

Journal of the American Board of Family Medicine. 2023

Is shared decision-making associated with better patient-reported outcomes? A longitudinal study of patients undergoing total joint arthroplasty. 

Clinical Orthopaedics and Related Research. 2022

Is the promise of PROMs being realized? Implementation experience in a large orthopedic practice. 

American Journal of Medical Quality. 2022

Strategies for dose optimization: views from health care systems. 

Journal of the American College of Radiology. 2022

What do orthopaedists believe is needed for incorporating patient-reported outcome measures into clinical care? A qualitative study. 

Clinical Orthopaedics and Related Research. 2022

Barriers to CT dose optimization: the challenge of organizational change. 

Academic Radiology. 2021

Personalized outcomes for hip and knee replacement: the patient's point of view. 

Journal of patient-reported outcomes. 2021

What's important: postoperative care planning. Recognizing the central role of pets in many patients' lives. 

Journal of Bone and Joint Surgery (American Volume). 2021

Organizational factors and quality improvement strategies associated with lower radiation dose from CT examinations. 

Journal of the American College of Radiology. 2020

What outcomes matter to patients after joint or spine surgery?. 

Journal of patient-centered research and reviews. 2020

Analysis of computed tomography radiation doses used for lung cancer screening scans. 

JAMA internal medicine. 2019

Potentially preventable hospital and emergency department events: lessons from a large innovation project. 

The Permanente journal. 2018

Reducing diabetes distress and improving self-management with mindfulness. 

Social Work in Health Care. 2018

Clinician burnout and satisfaction with resources in caring for complex patients. 

General Hospital Psychiatry. 2017

Impact of a national collaborative care initiative for patients with depression and diabetes or cardiovascular disease. 

General Hospital Psychiatry. 2017

Patient-centered outcomes measurement: does it require information from patients?. 

Journal of patient-centered research and reviews. 2017

A statewide effort to implement collaborative care for depression: reach and impact for all patients with depression. 

Medical Care. 2016

Predictors of poor response to depression treatment in primary care. 

Psychiatric Services. 2016

The effects of patient-centered depression care on patient satisfaction and depression remission. 

Family Practice. 2016

A stepped-wedge evaluation of an initiative to spread the collaborative care model for depression in primary care. 

Annals of Family Medicine. 2015

Impact of health information exchange on emergency medicine clinical decision making. 

Western Journal of Emergency Medicine. 2015

It is time to ask patients what outcomes are important to them

2015

Minnesota's early experience with medical home implementation: viewpoints from the front lines. 

Journal of General Internal Medicine. 2015

Organizational factors and change strategies associated with medical home transformation. 

American Journal of Medical Quality. 2015

Preventing chronic pain: a human systems approach-results from a massive open online course. 

Global advances in health and medicine. 2015

The effect of achieving patient-reported outcome measures on satisfaction. 

Journal of the American Board of Family Medicine. 2015

Assessing organizational readiness for depression care quality improvement: relative commitment and implementation capability. 

Implementation science. 2014

Challenges of medical home transformation reported by 118 patient-centered medical home (PCMH) leaders. 

Journal of the American Board of Family Medicine. 2014

Dietary fiber supplementation for fecal incontinence: a randomized clinical trial. 

Research in Nursing and Health. 2014

Effective implementation of collaborative care for depression: what is needed?. 

American Journal of Managed Care. 2014

Healthcare utilization and costs in persons with insomnia in a managed care population. 

American Journal of Managed Care. 2014

How much shared decision making occurs in usual primary care of depression? . 

Journal of the American Board of Family Medicine. 2014

National prevalence of receipt of antidepressant prescriptions by persons without a psychiatric diagnosis. 

Psychiatric Services. 2014

Patient experience and physician/staff satisfaction in transforming medical homes

2014

The effect of depression treatment on work productivity. 

American Journal of Managed Care. 2014

Barriers to improving primary care of depression: perspectives of medical group leaders. 

Qualitative Health Research. 2013

Designing and implementing research on a statewide quality improvement initiative: the DIAMOND study and initiative. 

Medical Care. 2013

Medical home transformation: a gradual process and a continuum of attainment. 

Annals of Family Medicine. 2013

Mindfulness-based stress reduction for family caregivers: a randomized controlled trial. 

The Gerontologist. 2013

Stress, burnout, compassion fatigue, and mental health in hospice workers in Minnesota. 

Journal of Palliative Medicine. 2013

The DIAMOND initiative: implementing collaborative care for depression in 75 primary care clinics. 

Implementation science. 2013

Prevalence of practice system tools for improving depression care among primary care clinics: the DIAMOND initiative. 

Journal of General Internal Medicine. 2011

Recruiting and retaining family caregivers to a randomized controlled trial on mindfulness-based stress reduction. 

Contemporary Clinical Trials. 2011

Severity of depression and magnitude of productivity loss. 

Annals of Family Medicine. 2011

Symptoms associated with dietary fiber supplementation over time in individuals with fecal incontinence. 

Nursing Research. 2011

Use and evaluation of disposable absorbent products for managing fecal incontinence by community-living people. 

Journal of Wound, Ostomy and Continence Nursing. 2011

Comparing community and specialty provider-based recruitment in a randomized clinical trial: clinical trial in fecal incontinence. 

Research in Nursing and Health. 2010

Goals of fecal incontinence management identified by community-living incontinent adults. 

Western Journal of Nursing Research. 2010

Effects of paroxetine and sertraline on low-density lipoprotein cholesterol: an observational cohort study. 

CNS drugs. 2009

Mindfulness-based stress reduction and diabetes. 

Diabetes Spectrum. 2009

Depression in patients with diabetes: does it impact clinical goals?. 

Journal of the American Board of Family Medicine. 2008

Measuring an organization's ability to manage change: the change process capability questionnaire and its use for improving depression care. 

American Journal of Medical Quality. 2008

Relationship between the presence of practice systems and the quality of care for depression. 

American Journal of Medical Quality. 2008

The family caregiver: an invisible (and stressed-out) member of your care team. 

Minn Physician. 2008

Variation in quality of diabetes care at the levels of patient, physician, and clinic. 

Preventing Chronic Disease. 2008

Use of practice system tools by medical groups for depression. 

American Journal of Managed Care. 2007

Community-based recruitment and enrollment for a clinical trial on the sensitive issue of fecal incontinence: the Fiber study. 

Research in Nursing and Health. 2006

Impact of office systems and improvement strategies on costs of care for adults with diabetes. 

Diabetes care. 2006

Characteristics of adults who use prayer as an alternative therapy. 

American Journal of Health Promotion. 2005

Health care charges associated with physical inactivity, overweight, and obesity. 

Preventing Chronic Disease. 2005

Predictors of health care costs in adults with diabetes. 

Diabetes care. 2005

The QUEST for quality: what are medical groups doing about it?. 

Joint Commission journal on quality and patient safety. 2005

Is patient readiness to change a predictor of improved glycemic control?. 

Diabetes care. 2004

Meeting recommendations for multiple healthy lifestyle factors. Prevalence, clustering, and predictors among adolescent, adult, and senior health plan members. 

American Journal of Preventive Medicine. 2004

Evaluation and treatment of depression. 

Office care geriatrics. 2006

Highly motivated population provides two successful recruitment methods into the TMD self-care study and PACT program [poster]

2018

PACT: a self-management program for chronic pain utilizing online education and telehealth coaching, findings of the pilot study [poster]

2018

Health care costs and utilization in patients with insomnia: higher medical expenses and declining health often follow treatment [poster]

2013

How to engage patients and clinicians as research partners, and have fun, too [poster]

2013

Improving diabetes management with mindfulness-based stress reduction [poster]

2013

DIAMOND: what predicts poor response to usual depression treatment in primary care? [poster]

2012

Did adult liver transplant recipients who had hepatitis C prior to transplant receive antiviral therapy, January 1997 to June 2009 [poster]

2012

Integrating patient and clinician perspectives in the TransforMN study [poster]

2012

DIAMOND Study: an innovative observational design model for patient-centered comparative effectiveness research [poster]

2011

Burnout, compassion fatigue, and coping among hospice caregivers [poster]

2010

MBSR (mindfulness-based stress reduction) for caregivers of people with dementia: the Balance Study [poster]

2010

The Minnesota Memory Project [poster]

2010

Absorbent product use and incontinence-associated dermatitis in community-living persons with fecal incontinence [poster]

2008

Are patient experiences of care among adults with diabetes related to health outcomes [poster]?

2006

EMR (Electronic Medical Record) use is not associated with better diabetes care [poster]

2006

Is patient satisfaction related to metabolic control in adults with diabetes [poster]?

2006

Management of adults with chronic kidney disease in primary care: gaps in care [poster]

2006

Patient and physician factors related to intensification of therapy in diabetes patient not at goal [poster]

2006

Patient and physician factors related to the receipt of a diagnosis of depression [poster]

2006

The impact of transitional care and continuity of care in an older population on hospitalist practice [poster]

2006

Transitional care in a health care organization: outcomes of a post-hospital care and care in lieu of hospitalization [poster]

2006

Clinic characteristics that may impact diabetes care outcomes and costs: conceptual approach [poster]

2005

Direct health care costs attributable to physical inactivity and obesity in patients with diabetes, heart disease, both, or neither [poster]

2003

Direct health care costs attributable to physical inactivity, overweight and obesity: analysis of health plan and national data [poster]

2003

Direct health care costs attributable to physical inactivity, overweight, and obesity: analysis of health plan and national data [poster]

2003

Health care costs attributable to physical inactivity, overweight, and obesity: analysis of health plan data [poster]

2003

Organizational characteristics and chronic disease care: a conceptual model [poster]

2002

Health information exchange frequently changes emergency physician management plan [abstract]. 

Annals of Emergency Medicine. 2014

Improving mental health and diabetes management with mindfulness-based stress reduction [abstract] [presentation]

2014

Use of complementary and alternative medicine in people with diabetes [abstract]. 

Annals of Behavioral Medicine. 2010

Impact of mind-body and education-based interventions on physiologic markers of chronic stress in family caregivers of dementia patients [abstract]. 

Alternative Therapies in Health and Medicine. 2009

Recruitment and retention of caregivers for patients with dementia: the Balance Study [abstract]. 

Alternative Therapies in Health and Medicine. 2009

Stress, burnout, compassion fatigue and coping in Minnesota hospice workers [abstract]. 

The Gerontologist. 2009

EMR (Electronic Medical Record) is not associated with better diabetes care [abstract]. 

Diabetes. 2007

Impact of spiritual and religious beliefs and practices on clinical measures of diabetes care in adults [abstract]. 

Diabetes. 2006

Is patient satisfaction related to metabolic control in adults with diabetes [abstract]. 

Diabetes. 2006

Patient and physician factors related to intensification of therapy in diabetes patient not at goal [abstract]. 

Diabetes. 2006

Sub-acute/transitional care and the acute care episode: a comparison of episodic and annual medical costs in a geriatric population [abstract]. 

Annals of Emergency Medicine. 2006

Biopsychosocial and behavioral correlates of depression and sub-threshold depression in the elderly [abstract]. 

The Gerontologist. 2004

Is patient readiness to change a predictor of improved glycemic control [abstract]. 

Diabetes. 2004

Relative impact of glycemic control and cardiovascular comorbidity on subsequent resource use among adults with diabetes [abstract]. 

Diabetes. 2004

The impact of clinic and medical group characteristics on diabetes care outcomes in primary care clinics [abstract]. 

Diabetes. 2004

Decisional balance and physical activity predict body mass index among sedentary adults and seniors [abstract]. 

Medicine and Science in Sports and Exercise. 2003

Assessing potential selection bias in MCO and community survey data [presentation], HMO Research Network (HMORN) 10th Annual Conference

Barriers to improving primary care of depression: a qualitative study [presentation], HMO Research Network (HMORN) 14th Annual Conference: Partnerships in Translation: Advancing Research and Clinical Care

Biopsychosocial and behavioral correlates of depression and sub-threshold depression in the elderly [presentation], HealthPartners Research Annual Conference

Challenges in recruiting family caregivers to a clinical trial on MBSR (mindfulness-based stress reduction) for stress reduction [presentation], Gerontological Society of America 63rd Annual Scientific Meeting

Diabetes care is no better in clinics that use electronic medical records (EMR) [presentation], AcademyHealth 24th Annual Research Meeting (ARM)

EMR (Electronic Medical Record) is not associated with better diabetes care [presentation], Minnesota Health Services Research 11th Annual Conference

EMR (Electronic Medical Record) use is not associated with better diabetes care [presentation], HMO Research Network (HMORN) 13th Annual Conference: Building a National Research Model: The Future of HMO-Based Research

Health care costs attributable to organizational characteristics: analysis of QUEST data [presentation], Building Bridges 11th Annual Conference: Applying Evidence-Based Solutions to Health Care Priorities

Impact of a learning healthcare network on depression outcomes: the DIAMOND initiative [presentation], NIMH (National Institute of Mental Health) 22nd Conference on Mental Health Services (MHSR), MHSR 2014: Research in Pursuit of a Mental Health Care System

Impact of clinic systems and improvement strategies on costs of care for adults with diabetes [presentation], AcademyHealth Annual Research Meeting

Impact of clinical systems and improvement strategies on costs of care for adults with diabetes [presentation], American Diabetes Association (ADA) 65th Annual Scientific Sessions

Improving diabetes management with mindfulness-based stress reduction [presentation], HMORN 20th Annual Conference: Embedded Research to Improve Health

Managing diabetes mindfully [presentation], American Association of Diabetes Educators MN Network Spring Symposium

Mindfulness-based stress reduction for caregivers: a randomized controlled pilot study [presentation], International Congress on Complementary Medicine Research (5th)

Predictors of poor response to usual depression treatment in primary care [presentation] , HMO Research Network (HMORN) 20th Annual Conference: Embedded Research to Improve Health

Psychotherapeutic prescription patterns across health plans in the Mental Health Research Network [presentation], HMO Research Network 17th Conference: Collaborations in Population-Based Health Research

Quality gaps in management of adults with chronic kidney disease in primary care [presentation], HMO Research Network (HMORN) 12th Annual Conference: Optimizing Practice Through Interdisciplinary Research

Readiness to change and diabetes care outcomes [presentation], Minnesota Health Services Conference

Stress reduction and caregiving: mindfulness as a path to balance [presentation], Minnesota Gerontological Society Annual Conference

Stress, burnout, compassion fatigue and coping among end-of-life care workers in Minnesota [presentation], Minnesota Health Services Research 14th Annual Conference

Sub-acute/transition care and the acute care episode: a comparison and episodic and annual medical costs in a geriatric population [presentation], Gerontological Society of America 59th Annual Scientific Meeting

Sub-acute/transition care and the acute care episode: a comparison and episodic and annual medical costs in a geriatric population [presentation], HMO Research Network (HMORN) 12th Annual Conference: Optimizing Practice Through Interdisciplinary Research

Sub-acute/transition care and the acute care episode: a comparison and episodic and annual medical costs in a geriatric population [presentation], American Geriatric Society Annual Scientific Meeting

Taking advantage of natural QI (quality improvement) experiments for implementation research: a DIAMOND opportunity [presentation], HMO Research Network (HMORN) 14th Annual Conference: Partnerships in Translation: Advancing Research and Clinical Care

Transformative self-management for chronic pain utilizing online training and telehealth coaching [presentation], Health Care Systems Research Conference

Transitional subacute care: outcomes of post-hospital care and care in lieu of hospitalization [presentation], Gerontological Society of America 59th Annual Scientific Meeting

Transitional subacute care: outcomes of post-hospital care and care in lieu of hospitalization [presentation], HMO Research Network (HMORN) 12th Annual Conference: Optimizing Practice Through Interdisciplinary Research

Using mindfulness-based stress reduction for caregivers of people with dementia [presentation], Minnesota Gerontological Society Annual Conference

Mindfulness-based stress reduction for caregivers [invited presentation], Minnesota Council on Family Relations Annual Conference

The perils of perception: the role of stress in diabetes [invited presentation], EBAN 3D Collaborative Meeting