TABLE 1.

Data Contained in the Case Studies

Sociodemographic factors:	Age, race, gender
Health state:	Medical diagnosis, comorbid conditions, past medical history, course of the hospitalization, adverse events during hospitalization; admission and discharge medications
Developmental state:	Mental status, education level, self-rated health, functional status, depression scores, language spoken
Health care system factors:	Previous home care use or hospitalization in last 6 mo or 30 d; doctor office or emergency department use, patient or family requests for services
Environmental factors:	Description of the home-location of bathroom and stairs; equipment used, requested or needed
Family system factors:	Marital status, support systems, living arrangements, primary caregiver availability and willingness
Patterns of living:	Substance use, habits, adherence history
Socioeconomic factors:	Insurance and income