Table 1 Key concepts and dependency, dependent variables

Functional Decline

ADL status worse as compared to 90 days ago

Overall self sufficiency has deteriorated as compared to 90 days ago

In a typical over last 30 days the person did not leave the house

Cognition/Communication

Worsening decision making as compared to status 90 days ago

Worsening communication (making self understood or understands others) as compared to status 90 days ago

Clinical Prognosis

Judged to have poor prospects of recovery from current disease or condition, improved health status expected

Has conditions or diseases that make cognition, ADL, mood, or behavior patterns unstable (fluctuations, precarious, or deteriorating)

Experiencing a flare-up of a recurrent or chronic problem

Near end of life: Prognosis of less than 6 months to live or in hospice or receiving respite care

Shortness of breath

Self reported poor health

Presence of a pressure ulcer

Service Use

Admitted to hospital for overnight stay in last 90 days

Emergent care – including unscheduled nursing, physician, or therapeutic visits to office or home

Daily nurse monitoring over last 7 days

Physician or clinic visit over last 7 days