Table 3 Mi Puente Behavioral Health Screener and Eligibility Determination

 Medication adherence

1 item

This study-specific item asks patient to indicate the number of days recommended medication doses were missed in the past 7 days.

Missed “sometimes,” “often,” or “always”

 Healthcare utilization

5 items

This study-specific measure assesses routine medical care access/use in the past 3 months. Lack of routine medical care is defined as: No routine medical exam, or patient unable to recall date of last routine medical exam; patient not able to receive health care when needed, or; patient endorses uses emergency room or hospital outpatient department for routine medical care.

Lack of routine medical care

 Alcohol

4 items: Alcohol Use Disorders Identification Test-C (AUDIT-C)

This measure screens for risky drinking behaviors based on sex-specific cut scores. Scores ≥ 5 for men (i.e., consuming ≥ 14 drinks per week or ≥ 5 drinks in one occasion ≥ 1 times per month) and ≥ 4 for women (i.e., consuming ≥ 7 drinks per week or ≥ 4 drinks in one occasion ≥ 1 times per month), may be indicative of hazardous drinking. This measure has demonstrated validity in both men and women in primary care settings [50] and has been recommended for use in general health screening [51].

Women: score ≥ 4Men: score ≥ 5

 Smoking

1 item

This item assesses if patient currently smokes cigarettes (Yes/No).

Endorses current smoking

 Anxiety symptom screener

2 items: Generalized Anxiety Dissorder-2 (GAD-2)

This scale assesses the frequency of anxiety symptoms experienced over the past 2 weeks [52].Scores ≥ 3 may be indicative of an anxiety disorder. This measure has demonstrated validity across diverse primary care patients ([52], including Spanish-speakers [53].

Score ≥ 3

 Depression symptom screener

2 items: Patient Health Questionnaire (PHQ-2)

This scale assesses the frequency of depressed mood and anhedonia over the past 2 weeks. Scores ≥ 3 may be indicative of clinical depression. This measure has demonstrated validity in primary care [54] and general medical outpatients [55].

Score ≥ 3

 Chronic stress

12 items: Chronic Burden Scale

Assesses the number of current ongoing problems of at least 6 months duration in major life domains (i.e., financial, work, relationship, health problems in self or close other, drug or alcohol problems in close other, caregiving, other chronic stressor) [56]. This measure has been used in prior multi-ethnic and Hispanic cohort studies [57, 58], and scores shown to relate to cardiometabolic disorders and risk factors [58,59,60].

Score ≥ 1 chronic stressor

 Chronic health problem distress

2 items

Diabetes Distress Screener [61], adapted to assess distress associated with chronic health problems experienced in the past month. Specifically, the participant felt “overwhelmed by the demands of living with chronic health problems” or felt he/she was “failing with health care regimen.”

Score ≥ 6

 Telephone access

1 item

Assesses if patient has access to a United States based telephone number that can be used for the duration of the study.

Telephone access endorsed