Table 3.

Key behavioral, social, and clinical risk factors, and additional services needed, identified by advanced practice provider and entered into COMPASS-CP during follow-up clinic visit, July 2016-February 2018 ^*

Domain	N	n (%)
Behavioral / Lifestyle Risk Factors †
Low Physical Activity (<20 minutes/day)	793	374 (47.2)
Current Smoking	807	147 (18.2)
Alcohol Use Over Recommended Daily Limit‡	807	29 (3.6)
Current Recreational Drug Use	807	20 (2.5)
Social Risk Factors †
No Able and Willing Caregiver	802	48 (6.0)
Clinical Risk Factors †
Communication Deficits Requiring Speech Therapy	805	79 (9.8)
Systolic Blood pressure >140 mmHg	805	298 (37.0)
LDL Cholesterol > 100 mg/dL	634	317 (50.0)
Diabetic with Hemoglobin A1C > 8.0%	478	84 (17.6)
International Normalized Ratio < 1.9 or 3.1 §	114	96 (84.2)
Need for additional services identified
Assisted Living	871	49 (5.6)
Skilled Nursing Facility	871	4 (0.5)
Home Health Occupational/Physical Therapy	871	426 (48.9)
Home Health Speech Therapy	871	104 (11.9)
Home Health Nursing	871	764 (87.7)

^*These questions did not require complete data entry to proceed, so sections could be skipped, leading to some missing values.

^†Excludes those with missing advanced practice provider form or missing or invalid response.

^‡For alcohol use, the threshold for women is 1 drink/day, and for men, 1–2 drinks/day.

^§Among patients anticoagulated with warfarin and with prothrombin measurements taken