30 closest matches · ranked by relevance
Alzheimer Disease · Dementia
Primary: Hospital Transfers — 1.2; 1.3 number of hospital transfers — p=0.3313
Automated Communication Tools · Complex Medical Patients
Primary: Medication Errors at Hospital Discharge — 645; 359 Errors
Dementia · Mild Cognitive Impairment
Primary: Documentation of PPC Discussion — 72; 106 Participants
Multiple Chronic Conditions
Primary: Treatment Burden — 11.9; 11.6; 12.7; 17.9 score on a scale
ESRD
Primary: Kidney Disease Quality of Life (KDQOL-36) Mean Scale Scores at Baseline, 6, 12 and 18 Months: Unadjusted — 35.5; 38.4; 36.3; 36.8 units on a scale
Diabetes · Asthma · Chronic Obstructive Pulmonary Disease
Primary: Patient Activation — 61.87; 63.73; 63.82; 63.15 score on a scale — p=0.0211
Primary Care
Primary: Consultation and Relational Empathy (CARE) Measure — 44.69; 41.99 units on a scale — p=0.029
Multiple Chronic Conditions · Dementia
Primary: Self-reported Perceived Value of Patient Priorities Care (PPC) Approach — 75; 85.7 percentage of participants
Primary Health Care · Quality of Health Care · Comorbidity
Primary: Aggregate Measure of Guideline-Based Clinical Care Gaps — 184; 210 Participants
Diabetes Mellitus, Type 2 · Congestive Heart Failure · Obstructive Pulmonary Disease
Primary: Number of Rehospitalizations Within 60 Days After Hospital Discharge — 807 rehospitalizations
Post Traumatic Concerns · Post Traumatic Stress Disorder · Depression and Suicide Ideation
Primary: Change in Post Traumatic Concerns Over the Course of the Six Months After Injury — 80; 83; 55; 59 Participants — p==0.01
Chronic Obstructive Pulmonary Disease
Primary: Mean Number of Chronic Obstructive Pulmonary Disease (COPD)-Related Hospitalizations and Emergency Department (ED) Visits Per Patient Within Each Study Arm — 0.72; 1.40…
Palliative Care
Primary: Hospital Site of Death: Number of Decedents Cared for in an Enrolled and Assigned NH Facility, Who Were Transferred to a Hospital and Died in the Hospital During the…
Other Cancer
Primary: Number of Participants With Advance Care Planning Documentation — 0; 1163; 349; 901 Participants — p=<0.05
Liver Cancer · Anxiety Disorder · Depression
Primary: Change in Quality of Life (QOL) From Baseline to Week 12 Per the Functional Assessment of Cancer Therapy-General (FACT-G) — 3.35; 0.12 units on a scale — p=0.104
Palliative Care · Critical Illness · Aging
Primary: Needs; Existential Concerns; Symptoms; and Therapeutic Interaction (NEST) Scale Total Score — 28.5; 29.3 score on a scale — p=1.00
Palliative Care · Advance Care Planning · Skilled Nursing Facilities
Primary: Number of Participants Who Completed Patient Quality of Life Surveys — 10; 35; 10; 35 participants
Terminal Conditions, End of Life
Primary: Presence of an Active Opioid Order at Time of Death — 1330; 1543 Participants — p=0.445
Cardiac Condition
Primary: See Primary Outcome Description Below — 8; 3; 8; 3 participants
Breast Cancer · Colorectal Cancer
Primary: Proportion of Complex Cancer Survivors Meeting Quality of Care Guidelines for Chronic Conditions and Follow-up Cancer Surveillance
Bipolar Disorder
Primary: To Reduce the Use of Health Care Services by Quantifying the Number of Hospitalizations — 12; 1 Hospitalizations
Asthma
Primary: Change From Baseline in the Proportion of Patients With an ICS-based Maintenance and/or Reliever Treatment — 571; 723 Participants — p=<.0001
Multimorbidity
Primary: Number of Participants Experiencing Repeat ED Use — 64; 59 Participants
Care Transitions
Primary: Hospital Readmission — .956; .949; .698; .972 odds ratio
Patient Computer Dialog
Primary: Patient Post Medical History Assessment Questionnaire — 8.4; 8.3 units on a scale
Adverse Events · Readmissions · Patient Engagement
Primary: Proportion of Participants With an Adverse Event Within 30 Days After Index Discharge Date — 0.18; 0.23 proportion of participants — p=0.02
Advanced Cancer · End Stage Organ Failure
Primary: Change in Quality of Life for Patients, as Measured by the Functional Assessment of Cancer Therapy - General (FACT-G) — 3.7; 3.1 score on a scale
Cancer
Primary: Number of Participants Compliant With Follow-up Care Visits — 47; 53; 44 Participants
Chronic Disease
Primary: Health Care Utilization — 7; 8; 4; 3 events
Chronic Kidney Disease · Diabetes · Hypertension
Primary: All Cause Hospitalizations for Patients With a Triad of Chronic Kidney Disease, Diabetes and Hypertension — 20.7; 21.12 percentage of participants hospitalized