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