Box 1 Summit A-ICU study enrollment criteria

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.