Table 1. Intervention bundle elements.

S/N	Intervention bundle elements	Risk score
		Low	High
1	Risk stratification with high-risk flag in EMR	X	X
2	Comprehensive and accurate discharge summary (to improve communication between hospital and primary care settings)	X	X
3	Medication reconciliation (to eliminate outdated medications)	X	X
4	Postdischarge phone call within 72 h of discharge		X
5	Posthospital visits at specialist clinic or polyclinic within 1 wk		X
6	Posthospital home visit		X
7	Initialization of Advance Care Planning (to assess patients' wishes regarding the future health care options)		X
8	Complex-case conference with multidisciplinary teams for patients staying more than 14 days and high risk of readmission		X

Abbreviation: EMR, electronic medical record.