Table 2.

Primary and secondary outcomes

Outcome	Usual care N = 428 N (%)	Intervention N = 423 N (%)	Unadjusted HR* (95 % CI)	aHR** (95 % CI)
Hospital readmission or ER visit	92 (21.5)	97 (22.9)	1.09 (0.82–1.45)	1.04 (0.78–1.39)
Hospital readmission	66 (15.4)	61 (14.4)	0.94 (0.67–1.34)	0.94 (0.63–1.28)
ER visit	85 (19.9)	89 (21.0)	1.08 (0.80–1.45)	1.03 (0.76–1.39)

*HR represents risk of outcome over 30 days with intervention, using usual-care group as reference, ** Covariate adjustment includes age, sex, race, marital status, insurance type, study site, presence of PCP, cognitive status, diagnosis, length of stay, number of discharge medications, presence of prior hospitalizations, and Morisky score (baseline medication adherence) and health literacy