Table 2.

Demographic and clinical data available in electronic health records.

IDENTIFICATION, patient ID
Referent Physician
Referent Nurse
Clinical Risk Group	See description in text
Risk of admission	See description in text
Adjusted Morbidity Group	See description in text
Age
Previously identified as “Advanced chronic disease and life limited prognosis” (MACA)	Yes □	No □
Previously identified as “Complex Chronic Patient” (PCC)	Yes □	No □