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. 2014 Apr 1;17(4):435–447. doi: 10.1089/jpm.2013.0214
Exclusion criteria: □ significant dementia or delirium
  □ psychosis
  □ hospitalization for suicidal ideation in the last year
  □ fewer than 3 outpatient visits with the resident
  □ less than 3 days in hospital (acute care only)
  □ non-English speaking
  □ less than 18 years of age
  □ no address in medical record
  □ prisoner
  □ other:__________________________________________