Patient subject number: [ ] [ ] [ ] Provider subject number: [ ] [ ] [ ]

The information from this survey is confidential and will be used for research purposes only. HIC # 1010007513.
1) How much did each of the following factors influence your decision to admit this patient?
[place a  in the box for the most appropriate response for each factor]
FACTOR / DEGREE OF INFLUENCE
Acuity of condition
(disease severity; patient needs immediate inpatient-level care) / Strong / Moderate / Weak / None
Availability of information about baseline condition
(inadequate clinical information; unable to access patient’s health records or discuss case with primary provider) / Strong / Moderate / Weak / None
Recent emergency department visit
(patient was recently seen in emergency department for similar complaint) / Strong / Moderate / Weak / None
Language barrier
(difficulty communicating or ensuring appropriate discharge plan) / Strong / Moderate / Weak / None
Availability of imaging
(patient needs imaging that he/she won’t get in timely fashion if discharged) / Strong / Moderate / Weak / None
Availability of other diagnostic testing or procedure
(needs diagnostic testing other than imaging that patient won’t get in timely fashion if discharged) / Strong / Moderate / Weak / None
Primary care access
(doesn’t have a primary care provider or won’t get appropriate, timely follow up if discharged) / Strong / Moderate / Weak / None
Specialty care access
(can’t get outpatient specialty care within reasonable amount of time; patient will get expedited specialty care or ambulatory procedure with admission) / Strong / Moderate / Weak / None
Coordination of hospice or long-term care placement
(needs hospice, nursing home, or other ECF care) / Strong / Moderate / Weak / None
Level of required nursing care
(patient has nursing care, but needs increased level of care, such as IV antibiotics) / Strong / Moderate / Weak / None
Likelihood of patient adherence
(has poor insight into illness; unreliable; unlikely to return as directed/needed; unable to understand and follow directions; unlikely to take medications) / Strong / Moderate / Weak / None
Psychiatric condition
(has poorly controlled mental illness that is not primary reason for admission, but could affect ability to care for self) / Strong / Moderate / Weak / None
Insurance status / Financial concerns
(uninsured; can’t afford outpatient workup or treatments, medications) / Strong / Moderate / Weak / None
Living situation / Social support
(lives alone; homeless; poor social support; toxic home environment; no one to help with ADLs) / Strong / Moderate / Weak / None
Transportation
(would have difficulty getting to appointments, obtaining medications, or returning to ED if condition worsens; lives far away) / Strong / Moderate / Weak / None
Compassion for situation
(new cancer or other serious diagnosis; needs to establish care team and would benefit from inpatient coordination) / Strong / Moderate / Weak / None

2) Was a care coordinator involved in this case?  Yes  No

If yes, did he/she attempt to facilitate alternative disposition? Yes  No  Not applicable