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Systems Transformation References

  1. Collins L, Ross L, Ugiagbe M. Clinical practice review on population health management and promoting positive health outcomes. J Hosp Manag Health Policy. 2023;7:23. doi:10.21037/jhmhp-23-106

  2. DeLaroche AM, Saysana M, Srinivasan S, et al. Bridging the gaps in pediatric complex healthcare: the case for home nursing care among children with medical complexity. BMC Health Serv Res. 2024;24:836. doi:10.1186/s12913-024-11235-1

  3. Lodge M, Bashiri S, Durazo-Arvizu R, Russell CJ. The association between home health nursing and 30-day hospital readmission after tracheostomy in children: a single-center prospective cohort study. Home Healthc Now. 2024;42(6):323–330. doi:10.1097/NHH.0000000000001294

  4. Maternal and Child Health Bureau. Enhancing systems of care for children with medical complexity. HRSA; 2023. https://mchb.hrsa.gov/programs/systems-medical-complexity

  5. Scheller E, Martinez D, Murillo M, Bashiri S, Lodge M. Readmission and mortality among children requiring long-term mechanical ventilation via tracheostomy: a systematic review. BMC Pulm Med. 2025;25:385. doi:10.1186/s12890-025-03818-3

  6. Schroeder AR, Neus B, Borges LE, Halpern-Felsher B. Healthcare utilization of complex chronically ill children managed by a telehealth-based team. Front Pediatr. 2021;9:689572. doi:10.3389/fped.2021.689572

  7. Teisberg EO, Wallace S, O'Hara S. Defining and implementing value-based health care: a strategic framework. Acad Med. 2020;95(5):682–685. doi:10.1097/ACM.0000000000003122​

Innovation References

  1. Alobayli F, O’Connor S, Holloway A, Cresswell K. Electronic health record stress and burnout among clinicians in hospital settings: a systematic review. SAGE Open Med. 2023;11:20552076231220241. doi:10.1177/20552076231220241

  2. Abu-Odah H, Molassiotis A, Liu J. Identifying barriers and facilitators of translating research evidence into clinical practice: a systematic review of reviews. Health Soc Care Community. 2022;30(2):e275–e285. doi:10.1111/hsc.13898

  3. Finney Rutten LJ, Ridgeway JL, Griffin JM. Advancing translation of clinical research into practice and population health impact through implementation science. Mayo Clin Proc. 2024;99(4):665–676. doi:10.1016/j.mayocp.2023.01.007​​

  4. Office of the National Coordinator for Health Information Technology. Hospital trends in the use, evaluation, and governance of predictive AI, 2023–2024. HealthIT.gov; 2024. https://healthit.gov/data/data-briefs/hospital-trends-use-evaluation-and-governance-predictive-ai-2023-2024

  5. Olawade DB, Weerasinghe K, Teke J, et al. The integration of artificial intelligence into clinical medicine: trends, challenges, and future directions. J Med Surg Public Health. 2024;3:100108. doi:10.1016/j.glmedi.2024.100108

  6. Schwamm LH, Pletcher S, Erskine A. AI and technology enabled clinical workflow redesign. Telemed Rep. 2024;5(1):415–420. doi:10.1089/tmr.2024.0079

  7. Warsame AM, Tahsin F, Sahi G, et al. Usability challenges in electronic health records: impact on documentation burden and clinical workflow: a scoping review. JAMIA Open. 2025;8(2):ooaf053. doi:10.1093/jamiaopen/ooaf053

Value Creation References

  1. ​​ Agrawal S. Home nursing care: Who should get it, and how much? An analysis of state-by-state diversity. Complex Child. Published September 2015. https://complexchild.org/articles/2015-articles/october/home-nursing-care

  2. Anshory M, Kuan WS, Rohman MS, et al. Can non-invasive cardiac hemodynamics and fluid content system (NICaS) parameters predict acute heart failure outcomes in Caucasian and Asian patients in the emergency department? Adv Med Sci. 2024;69(1):81-89. doi:10.1016/j.advms.2024.02.005

  3. Berry JG, Hall M, Neff J, et al. Children with medical complexity and Medicaid: spending and cost savings. Health Aff (Millwood). 2014;33(12):2199–2206. doi:10.1377/hlthaff.2014.0828

  4. Berry JG, Hall M, Hall DE, et al. Inpatient growth and resource use in 28 children’s hospitals: a longitudinal, multi-institutional study. JAMA Pediatr. 2013;167(2):170–177. doi:10.1001/jamapediatrics.2012.3008

  5. Centers for Medicare and Medicaid Services. CMS National Quality Strategy. Published April 2023. Accessed April 2, 2023. QualityStrategy@cms.hhs.gov

  6. Cheko J, Patsalis N, Kreutz J, et al. Acute hemodynamic changes induced by cardiac contractility modulation evaluated using the NICaS® system: a pilot study. J Clin Med. 2025;14(7):2172. doi:10.3390/jcm14072172

  7. Cohen E, Berry JG, Camacho X, Anderson G, Wodchis W, Guttmann A. Patterns and costs of health care use of children with medical complexity. Pediatrics. 2012;130(6):e1463–e1470. doi:10.1542/peds.2012-0175

  8. Cohen E, Kuo DZ, Agrawal R, et al. Children with medical complexity: an emerging population for clinical and research initiatives. Pediatrics. 2011;127(3):529–538. doi:10.1542/peds.2010-0910

  9. Connor JA, LaGrasta C, Hickey PA. Refinement of the Intensive Care Unit Complexity Assessment and Monitoring to Ensure Optimal Outcomes III acuity tool. Dimens Crit Care Nurs. 2022;41(3):144–150. doi:10.1097/DCC.0000000000000523

  10. Connor JA, Lagrasta C, Gauvreau K, Porter C, O’Brien K, Hickey PA. Validation of the Complexity Assessment and Monitoring to Ensure Optimal Outcomes (CAMEO II) acuity tool for pediatric critical care nursing. Dimens Crit Care Nurs. 2019;38(3):153–159. doi:10.1097/DCC.0000000000000355

  11. Connor JA, Lagrasta C, Gauvreau K, Porter C, O’Brien K, Hickey PA. Scaling the measurement of pediatric acuity using the Complexity Assessment and Monitoring to Ensure Optimal Outcomes (CAMEO II) tool. Dimens Crit Care Nurs. 2019;38(3):146–152. doi:10.1097/DCC.0000000000000356

  12. Cotter G, Moshkovitz Y, Kaluski E, et al. Accurate, noninvasive continuous monitoring of cardiac output by whole-body electrical bioimpedance. Chest. 2004;125(4):1431-1440. doi:10.1378/chest.125.4.1431

  13. Curran JA, Breneol S, Vine J. Improving transitions in care for children with complex and medically fragile needs: a mixed methods study. BMC Pediatr. 2020;20(1):219. doi:10.1186/s12887-020-02117-6

  14. Feinstein JA, Davidson A, Feudtner C. Pediatric Complex Chronic Condition System Version 3. JAMA Netw Open. 2024;7(7):e2420579. doi:10.1001/jamanetworkopen.2024.20579

  15. Feudtner C, Feinstein JA, Zhong W, Hall M, Dai D. Pediatric complex chronic conditions classification system version 2: updated for ICD-10 and complex medical technology dependence and transplantation. BMC Pediatr. 2014;14:199. doi:10.1186/1471-2431-14-199

  16. Feria-Clement FL. Use of the CAMEO II Acuity Tool to Decrease Burnout for Nurses Working in a Pediatric Intensive Care Unit [doctoral dissertation]. Abilene Christian University; 2020.

  17. Foster CC, Agrawal RK, Davis MM. Home health care for children with medical complexity: workforce gaps, policy, and future directions. Health Aff (Millwood). 2019;38(6):987–993. doi:10.1377/hlthaff.2018.05531

  18. Gay JC, Thurm CW, Hall M, et al. Home health nursing care and hospital use for medically complex children. Pediatrics. 2016;138(5):e20160530. doi:10.1542/peds.2016-0530

  19. Greco B, Chait Y, Nathanson BH, Germain MJ. A novel hypertension management algorithm guided by hemodynamic data. Kidney Int Rep. 2022;7(2):330-333. doi:10.1016/j.ekir.2021.11.029

  20. Guerrero E, et. al. Advancing theory on the multilevel role of leadership in the implementation of evidence-based health care practices. Health Care Manage Rev. 2018 Jun 25. doi: 10.1097/HMR.0000000000000213. [Epub ahead of print]. Author manuscript; available in PMC 2019 December 25.

  21. Harrigan RC, Ratliffe C, Patrinos ME, Tse A. Medically fragile children: an integrative review of the literature and recommendations for future research. Issues Compr Pediatr Nurs. 2002;25(1):1–20. doi:10.1080/014608602753504829NI Medical. Admission & hospitalization reduction.

  22. Henry J, Pylypchuk Y, Patel V. Electronic Health Record Adoption and Interoperability Among U.S. Skilled Nursing Facilities and Home Health Agencies in 2017. ONC Data Brief No. 41. Department of Health and Human Services, Office of the National Coordinator for Health Information Technology; 2018.

  23. Hessels A, Darby SW, Simpser E, Saiman L, Larson EL. National testing of the Nursing-Kids Intensity of Care Survey for Pediatric Long-term Care. J Pediatr Nurs. 2017;37:86–90. doi:10.1016/j.pedn.2017.08.026

  24. Koop CE. Families caring for disabled need long-term support. Health Progress. 1986;67(6):52–54.

  25. Kumar V.  Understanding cultural differences in innovation: a conceptual framework and future research directions. J Int’l Marketing. 2014; 22(3): 1-29.

  26. Kuo DZ, Melguizo-Castro M, Goudie A, Nick TG, Robbins JM, Casey PH. Variation in child health care utilization by medical complexity. Matern Child Health J. 2015;19(1):40–48. doi:10.1007/s10995-014-1493-0

  27. May CR. Agency and implementation: understanding the embedding of healthcare innovations in practice.  Soc Sci Med. 2013;78:26-33.

  28. Maynard R, Christensen E, Cady R, et al. Home health care availability and discharge delays in children with medical complexity. Pediatrics. 2019;143(1):e20181951. doi:10.1542/peds.2018-1951

  29. Mentro AM, Steward DK. Caring for medically fragile children in the home: an alternative theoretical approach. Res Theory Nurs Pract. 2002;16(3):161–177. doi:10.1891/rtnp.16.3.161.53012

  30. Navarra AM, Schlau R, Murray M, et al. Assessing nursing care needs of children with complex medical conditions: the Nursing-Kids Intensity of Care Survey (N-KICS). J Pediatr Nurs. 2016;31(3):299–310. doi:10.1016/j.pedn.2015.11.012​

  31. NI Medical; 2025. https://www.ni-medical.com/clinical-markets/admission-hospitalization-reduction/

  32. NI Medical. Skilled nursing facilities. NI Medical; 2025. https://www.ni-medical.com/clinical-markets/skilled-nursing-facilities/

  33. O’Reilly CA, Tushman ML. The ambidextrous organization. Harv Bus Rev. 2004; 82(4): 74-83.

  34. Rasooly IR, Shults J, Guevara JP, Feudtner C. State variation in posthospital home nursing for commercially insured medically complex children. Pediatrics. 2020;146(2):e20192465. doi:10.1542/peds.2019-2465

  35. Rozenman Y, Rotzak R, Patterson RP. Detection of left ventricular systolic dysfunction using a newly developed, laptop based, impedance cardiographic index. Int J Cardiol. 2011;149(2):248-250. doi:10.1016/j.ijcard.2011.02.029

  36. Simon TD, Haaland W, Hawley K, Lambka K, Mangione-Smith R. Development and validation of the Pediatric Medical Complexity Algorithm (PMCA) version 3.0. Acad Pediatr. 2018;18(5):577–580. doi:10.1016/j.acap.2018.02.010

  37. Simon TD, Whitlock KB, Haaland W, et al. Effectiveness of a comprehensive case management service for children with medical complexity. Pediatrics. 2017;140(6):e20171641. doi:10.1542/peds.2017-1641

  38. Sobotka SA, Gaur DS, Goodman DM, Agrawal RK, Berry JG, Graham RJ. Pediatric patients with home mechanical ventilation: The health services landscape. Pediatr Pulmonol. 2019;54(1):40–46. doi:10.1002/ppul.24196

  39. Sobotka SA, Dholakia A, Berry JG, et al. Home nursing for children with home mechanical ventilation in the United States: key informant perspectives. Pediatr Pulmonol. 2020;55(12):3465–3476. doi:10.1002/ppul.25078

  40. Steinbinder, Scott K. A. Innovation cycle for small land large-scale change. Nurs Adm Q. 2009;33(4):335-341.

  41. Tanino Y, Shite J, Paredes OL, et al. Whole-body bioimpedance monitoring for outpatient chronic heart failure follow up. Circ J. 2009;73(6):1074-1079. doi:10.1253/circj.CJ-08-0847

In Practice References

  1. ​Alyafei A, Easton-Carr R. The health belief model of behavior change. In: StatPearls. StatPearls Publishing; 2024. https://www.ncbi.nlm.nih.gov/books/NBK606120/

  2. Bandura A. Self-Efficacy: The Exercise of Control. W. H. Freeman; 1997.

  3. Mesko B, deBronkart D, Dhunnoo P, et al. The evolution of patient empowerment and its impact on health care’s future. J Med Internet Res. 2025;27:e60562. doi:10.2196/60562.

  4. Lunardi AC, Oliveira JM, Valderramas SR. The effectiveness of patient activation interventions in adults with chronic kidney disease: a systematic review and meta-analysis. Worldviews Evid Based Nurs. 2023;20(3):222-234. doi:10.1111/wvn.12634

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