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Evaluation

Are you discharging a patient from the hospital?

Age of the patient

years

Gender of the patient

Does the patient live alone with no or limited social support?

Number of comorbid conditions

Total number of hospital admissions for the patient in the past year (including the current one)

Number of visits by the patient to a primary care provider (PCP) in the past 12 months

Does the patient have moderate to severe disability?

Does the patient or the personal physician rate the patient's general health as poor?

Is the patient stable?

Does the patient have?

• coronary artery disease (CAD)?

• moderate to severe heart failure?

• moderate to severe chronic obstructive pulmonary disease (COPD)?

• advanced malignancy?

• dysphagia?

• diabetes mellitus?

• end-stage renal failure?

Results

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