|
Enrollment criteria
|
|
1 or more medical/surgical hospitalizations in last 6 months
|
|
1 or more of the following medical conditions:
|
|
Chronic kidney disease stage III
|
|
Congestive heart failure
|
|
Chronic obstructive pulmonary disease, group C/D
|
|
Diabetes with A1c > 8%
|
|
End Stage Liver Disease (ESLD)
|
|
Osteomyelitis/severe soft-tissue infection
|
|
Or 1 or more of the following co-morbid conditions
|
|
Mental health
|
|
Substance use disorder
|
|
Difficulty engaging in usual primary care (missed appointments)
|
|
Exclusion criteria
|
|
Inability to consent (as demonstrated by “teach-back” method)
|
|
Non-English speaking patients
|
|
On hospice or deemed < 6 months to live at time of enrollment
|
|
Diagnosis of terminal cancer
|
|
Inability to participate in follow up assessment due to aphasia, severe hearing impairment or behavioral issues.
|
