ID.1
Item
have hf as one of their discharge diagnoses;
boolean
ID.2
Item
have new york heart association (nyha) class ii to iv symptoms or have nyha class i symptoms
boolean
ID.3
Item
have had at least one other hf-related hospitalization or emergency department visit in the previous year;
boolean
ID.4
Item
are discharged to home;
boolean
ID.5
Item
pass a mini-cog screen
boolean
ID.6
Item
understand english;
boolean
ID.7
Item
have access to a phone.
boolean
ID.8
Item
have scheduled procedures and/or surgeries during hospitalization;
boolean
ID.9
Item
have depressive symptoms (receive a score of 3 or above on the patient health questionnaire-2 (phq-2) have documented medical diagnosis or diagnostic evidence of liver cirrhosis;
boolean
ID.10
Item
have renal failure (serum creatinine greater than 2.0mg/dl)
boolean