Table 1 Eligibility criteria
Inclusion criteria | Definition |
|---|---|
Diagnosis of CHF or COPD within 2 years prior to enrollment Diagnosis of ILD within 2 years prior to enrollment | Hospitalization discharge diagnosis or ≥ 2 outpatient visitsa,b Hospitalization discharge diagnosis or ≥ 1 outpatient diagnosis by a pulmonologistc |
Among those with CHF or COPD, high risk for hospitalization and death | CAN score ≥ 80 |
Poor quality of life | FACT-G score ≤ 70 |
Symptomatic | Bothered by at least one of the target symptoms: pain, fatigue, depression, shortness of breath, trouble sleeping |
Primary care or other provider who is willing to facilitate intervention medical recommendations | PCP listed in Electronic medical record review or self-report |
Able to read and understand English | Self-report |
Consistent access to and able to use a standard telephone | Self-report |
Exclusion criteria | |
 Previous diagnosis of dementia | Inpatient or outpatient diagnostic coded |
 Active substance abuse | Electronic medical record review for substance abuse in the previous 6 months |
 Comorbid metastatic cancer | Electronic medical record review |
 Diagnosis of obesity hypoventilation syndrome | Inpatient or outpatient diagnostic codee |
 Nursing home resident | Electronic medical record review or self-report |
 Heart or lung transplant or LVAD | Electronic medical record review or self-report |
 Participation in the intervention arm of the CASA trialf | Electronic medical record review |
 Enrolled in palliative care, hospice, or home-based primary care | Electronic medical record review or self-report |
 Prisoner | Electronic medical record |
 Pregnant | Electronic medical record or self-report |