Table 2 Study measures: demographic, clinical, covariate, and outcomes
| Â | Measures | ||
|---|---|---|---|
Measures | Timeline | Source/Approach | |
Demographic | Patient age, gender, marital status, race, ethnicity, education level, primary language, home ownership, living status, home address | Baseline | Patient survey |
Patient relationship with PCP | Baseline | Patient survey | |
Insurance plan | Baseline | Chart review | |
Clinical | New home services (since ED visit) | Day 4/Day 30 | Patient survey |
ED chief complaint, final diagnosis (ICD-10), discharge medications, and instructions | Baseline | Chart review | |
CTI Coaching & Services Forms  Personal Health Record (PHR)  Home Visit/PHR Discussion Checklist  Follow-up Phone Calls Checklist  Patient Activation Assessment  Medication Discrepancy Tool  Care Transitions Measure - 3 [40] | Home visit & coach follow up calls | CTI program records | |
Covariates | Medical history, including Charlson Comorbidity Index [41] | Baseline | Patient survey |
Healthcare: Medications, home services, ED / hospital use | Baseline | Patient survey/ Epic review | |
Health Status: Short Form-12 [42] | Baseline | Patient survey | |
Disability Status: ADL [43] | Baseline | Patient survey | |
Baseline | Patient survey | ||
Social Isolation: PROMIS Social isolation short form [46] | Baseline | Patient survey | |
Depression: PHQ-9 [47] | Baseline | Patient survey | |
Anxiety: GAD-2 [48] | Baseline | Patient survey | |
Health literacy | Baseline | Patient survey | |
Outcomes | Family Caregiver Activation in Transitions [49] | Baseline, Day 30 | Caregiver survey |
Understanding of red flags | Day 4 | Patient survey | |
Medication changes implemented | Day 4 | Patient survey | |
Follow up with PCP, specialists, urgent care | Day 4, 30 | Patient survey / Chart review | |
Wallston’s Perceived Health Competence Scale (PHCS) [50] | Baseline, Day 30 | Patient / Caregiver survey | |
Healthcare use within 30Â days of discharge | Day 30 | Patient survey / Chart review | |
Death within 30Â days of discharge (Social Security Death Index) | Day 30 | Death Index | |
Patient experiences of continuity | Day 30 | Patient survey | |
Cost of healthcare and CTI program | Day 30 | Health systems/ CTI program records | |
Program satisfaction | Day 30 | Patient / caregiver survey | |