Table 4.

Process Measures, 12-month Period of Observation

	Assignment
	N	Intervention N=114	N	Control N=112	P
# Days to HBPC telephone triage, mean (sd)a	72	25.8 (23.1)	-	-	-
# Days to first home-based primary care visit, mean (sd)a	74	86.3 (56.7)	-	-	-
# Days in HBPC, mean (sd)b	74	254 (82)	-	-	-
# Days to any in-person clinical encounter, mean (sd)a	93	57.3 (56.2)	87	59.8 (59.8)	.95
# Office-based clinical visits prior to first HBPC visit, median (range)	74	2 (0–5)	-	-	-
# Home-based primary care visits, median (range)	74	6 (2–15)	0	0	-
# Office-based primary care visits, median (range)	58	2 (1–14)	86	4 (1–13)	.003
Among intervention patients with no HBPC visits	23	5 (1–14)	-	-	-
# Telephone encounters with primary care, median (range)c	87	6 (1–34)	64	3 (1–14)	<.0001
Had specialty care referral	63	55.3%	49	43.8%	.08
# Specialty care referrals, median (range)		2 (1–13)		2 (1–8)	.90
Had any social work encounter	84	73.7%	43	38.4%	<.0001
# Social work in-person encounters, median (range)	33	1 (1–6)	13	2 (1–7)	.19
# Social work telephone encounters, median (range)	82	7 (1–37)	38	3 (1–17)	<.0001
Assessments
Falls	88	77.2%	73	65.2%	.046
Cognition	45	39.5%	10	8.9%	<.0001
Physical function	57	50.0%	30	26.8%	.0003
Signed MOLST form in medical record
At baseline	9	7.9%	7	6.3%	.63
At 12 months	28	24.6%	13	11.6%	.01
Documentation of DNR or DNI order
At baseline	6	5.3%	8	7.1%	.56
At 12 months	46	40.3%	23	20.5%	<.0001
Documentation of Do Not Hospitalize order
At baseline	0	-	0	-	-
At 12 months	7	6.1%	0	-	-

^aFrom date of randomization.

^bFrom date of randomization to study completion (12-month follow-up, death, or drop out).

^cIncludes physician, nurse practitioner, or nurse encounter.

MOLST, medical outcomes of life sustaining treatments; DNR, do not resuscitate; DNI, do not intubate.

P-values were calculated per intention-to-treat analysis.