Table 2.

Conceptual domains, measures, and data sources.

Domain	Measures	Data sources
Socio-economic factors	Age, sex, race and ethnicity, language, caregiver support, living arrangements, language spoken, and residence county	OASISa/VNSNYb EHRc
Clinical factors	Primary and background diagnoses, limitations in functioning, cognitive status, depressive symptoms, behavioral problems, wounds, pain, sensory status, elimination status, and medications	OASIS/VNSNY EHR
Health outcomes	Time from hospital discharge to first homecare visit, rehospitalizations, and EDd visits	Regional Health Information organization/ VNSNY EHR

^aOASIS: Outcome and Assessment Information Set.

^bVNSNY: Visiting Nurse Service of New York.

^cEHR: electronic health record.

^dED: emergency department.