Table 3.

Source and schedule of outcome, utilization, process, and other variables

			Post-discharge
Variable	Source/Instrument	Baseline	7-days	30-days	180-days
Outcomes
Readmission	UHC, OSHPD		X	X	X
Hospital days	UHC, OSHPD		X	X	X
Hospital cost	UHC, OSHPD
Emergency Dept use	OSHPD		X	X	X
Mortality	UHC, OSHPD, National Death Index		X	X	X
Quality of life	Survey/Minnesota Living with Heart Failure Questionnaire	X	X	X	X
Intervention process
Pre-discharge education completion and comprehension	Enrollment documentation notes	X
Post-discharge health coaching	Call center documentation notes		*	*	*
Remote monitor use	Daily data transmission reports		*	*	*
Calls triggered by remote monitoring	Data transmission reports, call center documentation notes		*	*	*
Patient assessment of care transition	Survey/Care Transition Measure-3		X
Covariates
Age	Survey, UHC	X
Gender	Survey, UHC	X
Race/Ethnicity	Survey, UHC	X
Language	Survey, language of consent	X
Household income	Survey	X
Education	Survey	X
Marital status	Survey	X
Insurance (for example, dual Medicaid/Medicare)	UHC	X
Employment	Survey/Health and Work Performance Questionnaire	X		X	X
Health literacy	Survey/REALM-R	X
Severity of illness	Survey/Total Illness Burden Index	X			X
Co-morbidities	UHC	X
Depression	Survey/Geriatric Depression Scale	X	X	X	X
Self-care behaviors	Survey/Self-Care of Heart Failure Index	X	X	X	X
Social networks	Survey/Lubben Social Network Scale	X		X	X
Informal caregiving	Survey/Medical Care Questionnaire	X		X	X
Medication adherence	Survey/Morisky Medication Adherence Scale		X	X	X
End-of-life wishes	Survey	X

*Signifies the measure is continuously available over the 180-day timeframe.

UHC is University HealthSystem Consortium; OSHPD is Office of Statewide Health Planning & Development.