Table 1 Data collection

Demographics

From BRFSS [49]

Race, ethnicity, place of birth

X

Acculturation

GBAS [23]

Language-based measure of acculturation

X

Income/socioeconomic status

Annual household income, difficulty paying bills, employment and education status

X

Social support

HRS, MIDUS, ESSI [33–35]

Marital status, number in household, number of close family/friends and frequency of contact, perceived social support

X

X

Health literacy

s-TOFHLA [30]

Ability to perform basic reading tasks typical of those encountered in the health care setting

X

Subjective health literacy

BHLS [31]

Confidence with written medical information

X

Subjective numeracy

SNS [32]

Preferences for numerical information

X

Cognition

SPMSQ [24]

Level of cognitive impairment

X

Access to care

Presence of a regular health care provider

X

Prior health care utilization

Number of hospital admissions, Emergency Department visits, and outpatient clinic visits during the last year

X

Medication adherence

ARMS [52]

Adherence to medication regimen

X

X

Quality of life

PROMIS* Global health status [27]

Physical functioning, pain, fatigue, emotional distress, and social health

X

X

X

Depression

PHQ-8 [47]

Presence and severity of depressive symptoms

X

X

Vulnerable Elders Survey (≥65 yrs only)

VES-13 [28]

Health status, functional ability, and physical fitness

X

X

X

Exhaustion (≥65 yrs only)

CES-D [29]

Perception that everything is an effort, trouble getting going

X

Health self-efficacy

PHCS [45]

Confidence in engaging in appropriate health-related behaviors

X

Problem-solving and Decision-making

PSDM [41]

Preferences in health-related problem-solving, decision-making

X

Diet

STC [50]

Healthy eating habits

X

Physical activity

Exercise vital sign [51]

Exercise frequency and duration

X

Smoking history

From BRFSS [49]

Past and current smoking status

X

Alcohol consumption

From BRFSS [49]

Current alcohol intake

X

Trust in health care system

RHCSDS [36]

General beliefs about the health care system

X

Resilient coping

BRCS [46]

Tendency to cope with stress in a highly adaptive manner

X

Religion/spirituality

Religious preference and denomination, intrinsic religious/spiritual orientation, and frequency of engaging in public or private religious/spiritual activities

X

Electronic health literacy

eHEALS [37]

Experience using the Internet for health information

X

Use of portals

Use of Vanderbilt online patient portal

X

Trust in hospital providers

WFPTS [42]

Interpersonal relationship between patient and providers

X

Quality of communication in hospital

IPC [43, 44]

Quality and clarity of communication between patient and provider

X

Preparedness for discharge

B-PREPARED [39]

Perceptions of the discharge planning process and their level of preparation

X

Quality of the care transition

CTM-3 [40]

Care transition experiences

X

Instrumental support

ISD

Support received with common care transition tasks

X

X

Stress post-discharge

Stress post-discharge, contribution of financial, social/family, work, health, or other factors to stress

X

Medication discrepancies [53]

Unintentional differences between hospital discharge regimen and what the patient thinks s/he should be taking

X

Medication understanding [54]

Understanding of drug indications and instructions for use

X

Outcomes: ER visits and hospitalization 

Unplanned healthcare utilization after discharge

X

X

Health-related quality of life

EQ-5D [55]

Mobility, self-care, usual activities, pain, and depression

X

X

Cardiac rehabilitation

Participation in cardiac rehab, and frequency (if participating)

X

X

Outcomes: mortality

Through 1 year after last patient is enrolled and discharged

Medical record abstraction

  Demographics

Age, gender

  Diagnosis

ACS, ADHF, or both

  Severity of illness

Including TIMI score, [25] ejection fraction

  Comorbidities

Including Elixhauser [26]

  Insurance type

Including private, Medicare, Medicaid, none, or other

  Utilization

Post-discharge ER visits and readmissions (to supplement patient-report)