Enrollment Primary Care Clinic
Item
enrolled in one of the three primary care clinics for at least one year
boolean
C1516879 (UMLS CUI [1,1])
C1552443 (UMLS CUI [1,2])
ICD Diagnosis Other Coding
Item
diagnosis icd (250.xx) in the prior year
boolean
C0870733 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
C3846158 (UMLS CUI [1,3])
Age
Item
18 years of age and older.
boolean
C0001779 (UMLS CUI [1])
Hospitalization Cerebrovascular accident | Hospitalization Myocardial Infarction | Hospitalization Coronary artery Revascularization
Item
hospitalized for a stroke, myocardial infarction, coronary artery revascularization in the past 6 months
boolean
C0019993 (UMLS CUI [1,1])
C0038454 (UMLS CUI [1,2])
C0019993 (UMLS CUI [2,1])
C0027051 (UMLS CUI [2,2])
C0019993 (UMLS CUI [3,1])
C0205042 (UMLS CUI [3,2])
C0581603 (UMLS CUI [3,3])
Dialysis Chronic Kidney Failure | Dialysis Planned Chronic Kidney Failure
Item
receiving or planning to receive dialysis for end stage renal disease
boolean
C0011946 (UMLS CUI [1,1])
C0022661 (UMLS CUI [1,2])
C0011946 (UMLS CUI [2,1])
C1301732 (UMLS CUI [2,2])
C0022661 (UMLS CUI [2,3])
Neoplasm Metastasis
Item
diagnosis of metastatic cancer
boolean
C0027627 (UMLS CUI [1])
Psychotic Disorders
Item
active diagnosis of psychosis documented in medical record
boolean
C0033975 (UMLS CUI [1])
Telephone Access Absent
Item
does not have access to a telephone
boolean
C0039457 (UMLS CUI [1,1])
C0444454 (UMLS CUI [1,2])
C0332197 (UMLS CUI [1,3])
Informed Consent Refused
Item
refusal to provide informed consent
boolean
C0021430 (UMLS CUI [1,1])
C1705116 (UMLS CUI [1,2])
Nursing home resident | Home Health Care
Item
resident in nursing home or receiving home health care
boolean
C0682287 (UMLS CUI [1])
C0019855 (UMLS CUI [2])
Visual Impairment Severe | Hearing impairment Severe | Speech impairment Severe
Item
severely impaired sight, hearing or speech
boolean
C3665347 (UMLS CUI [1,1])
C0205082 (UMLS CUI [1,2])
C1384666 (UMLS CUI [2,1])
C0205082 (UMLS CUI [2,2])
C0233715 (UMLS CUI [3,1])
C0205082 (UMLS CUI [3,2])
Relocation of home Planned
Item
planning to leave the area prior to the anticipated end of participation
boolean
C2699029 (UMLS CUI [1,1])
C1301732 (UMLS CUI [1,2])
Pregnancy | Pregnancy, Planned | Breast Feeding
Item
pregnant or planning to become or breast feeding.
boolean
C0032961 (UMLS CUI [1])
C0032992 (UMLS CUI [2])
C0006147 (UMLS CUI [3])