Table 1.

Survey Question Categories Used to Screen for Readmission Risk

	Extrinsic
Intrinsic	Care Coordination	Environmental
Worsening medical or surgical condition (chest pain, shortness of breath, etc.) Worsening mental or behavioral health problem (depression, noncompliance, etc.) Functional decline (needs help with more activities of daily living, worsening frailty, etc.)	Management of a specific condition Setting up primary care provider or specialist appointment Coordination issue remained unresolved (loop not closed) Skilled home care assessment, referral, or service Nonskilled home care assessment, referral, or service Behavioral health assessment, referral, or service Home safety assessment Other home and community services–based assessment, referral, or service Medications ordered and filled Medication reconciliation Ongoing medication management in the home (filling syringes, applying creams, etc.) Durable medical equipment ordered and filled Inadequate family or community support to help with function Patient or family education or health literacy	Financial insecurity (i.e., cannot afford basic necessities) Food insecurity (lack of access to high quality nutrition) Housing insecurity (risk of homelessness) Housing quality (bug or rodent infestations, elevator out, no heat, appliance not working, etc.) Violence or abuse Transportation (cannot get to appointments, etc.) Legal