Table 5 Mi Puente assessments of primary and secondary outcomes, behavioral health concerns, and demographic and social contextual factors

 Hospitalizations

EMR data for hospital utilization

X

X

X

n/a

 Physical symptoms/quality of life

PROMIS Global-10 Health Scale [76]

X

X

X

10

 Patient activation

Patient Activation Measure [77, 78]

X

X

X

13

 Support resources for disease management

Chronic Illness Resources Survey [67]

X

X

X

13

 Healthcare utilization

Health Utilization Questionnaire

X

X

X

12

 Healthcare access and barriers

Study-adapted measure

X

X

X

5

 Medication Adherence

Medication adherence

X

1

 Smoking

Smoking status

X

1

 Alcohol use

Alcohol screener (AUDIT-C) [51]

X

4

 Chronic stress

Chronic Burden Scale [56].

X

12

 Health-related distress

Study-adapted Diabetes Distress Screener [61],

X

2

 Depression

Patient Health Questionnaire 2-item [54]

X

2

 Anxiety

Generalized Anxiety Disorder 2-item [52].

X

2

 Demographic information

Age, sex, race, ethnicity, nativity, language, employment, income, education, marital status, housing

X

11

 Social support

Single Item Measure of Social Support [79]

X

X

X

1

 Fatalism

Fatalism scale [80]

X

X

X

10

 Health literacy

Single Item Literacy Screener [81]

X

X

X

1