|  |  | Post-discharge | ||
---|---|---|---|---|---|
Variable | Source/Instrument | Baseline | 7-days | 30-days | 180-days |
Outcomes | Â | Â | Â | Â | Â |
Readmission | UHC, OSHPD | Â | X | X | X |
Hospital days | UHC, OSHPD | Â | X | X | X |
Hospital cost | UHC, OSHPD | Â | Â | Â | Â |
Emergency Dept use | OSHPD | Â | X | X | X |
Mortality | UHC, OSHPD, National Death Index | Â | X | X | X |
Quality of life | Survey/Minnesota Living with Heart Failure Questionnaire | X | X | X | X |
Intervention process | Â | Â | Â | Â | Â |
Pre-discharge education completion and comprehension | Enrollment documentation notes | X | Â | Â | Â |
Post-discharge health coaching | Call center documentation notes | Â | * | * | * |
Remote monitor use | Daily data transmission reports | Â | * | * | * |
Calls triggered by remote monitoring | Data transmission reports, call center documentation notes | Â | * | * | * |
Patient assessment of care transition | Survey/Care Transition Measure-3 | Â | X | Â | Â |
Covariates | Â | Â | Â | Â | Â |
Age | Survey, UHC | X | Â | Â | Â |
Gender | Survey, UHC | X | Â | Â | Â |
Race/Ethnicity | Survey, UHC | X | Â | Â | Â |
Language | Survey, language of consent | X | Â | Â | Â |
Household income | Survey | X | Â | Â | Â |
Education | Survey | X | Â | Â | Â |
Marital status | Survey | X | Â | Â | Â |
Insurance (for example, dual Medicaid/Medicare) | UHC | X | Â | Â | Â |
Employment | Survey/Health and Work Performance Questionnaire | X | Â | X | X |
Health literacy | Survey/REALM-R | X | Â | Â | Â |
Severity of illness | Survey/Total Illness Burden Index | X | Â | Â | X |
Co-morbidities | UHC | X | Â | Â | Â |
Depression | Survey/Geriatric Depression Scale | X | X | X | X |
Self-care behaviors | Survey/Self-Care of Heart Failure Index | X | X | X | X |
Social networks | Survey/Lubben Social Network Scale | X | Â | X | X |
Informal caregiving | Survey/Medical Care Questionnaire | X | Â | X | X |
Medication adherence | Survey/Morisky Medication Adherence Scale | Â | X | X | X |
End-of-life wishes | Survey | X | Â | Â | Â |