Social and Functional Predictors of Rehospitalization: YCLS and PROMIS (SDH2)

This project aims to determine whether fields included in the National Institutes of Health’s Patient Reported Outcomes Measurement System (PROMIS) questionnaires for cognition and physical function, as well as those in the Your Current Life Situation (YCLS) questionnaire can enhance our ability to predict rehospitalization. 1600 patients will be interviewed shortly before their hospital discharge from the Kaiser Permanente Northern California Oakland, San Leandro, and Walnut Creek Hospitals. Patients at low or medium risk for rehospitalization will be oversampled. Data from the interviews will be combined with an existing real time rehospitalization score in use in all Kaiser Permanente Northern California hospitals. If successful, the project would permit better targeting of patients in need of support following hospitalization.

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