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Race/ethnicity as identified by patient: Native Hawaiian or Pacific Islander.
Race/ethnicity as identified by patient: Unknown.
Race/ethnicity as identified by patient: White
Current payment sources for home care: Medicaid (traditional fee-for-service).
Current payment sources for home care: Medicaid (HMO/managed care).
Current payment sources for home care: Medicare (traditional fee-for-service).
Current payment sources for home care: Medicare (HMO/managed care).
Current payment sources for home care: none, no charge for current services.
Current payment sources for home care: other government (e.g., Tricare VA, etc.).
Current payment sources for home care: other (specify).
Current payment sources for home care: private HMO managed care.
Current payment sources for home care: private insurance.
Current payment sources for home care: self-pay.
Current payment sources for home care: title programs (e.g., Title III, V, or XX).
Current payment sources for home care: unknown.
Current payment sources for home care: worker's compensation.
Financial factors limiting ability of patient/family to meet basic health needs: unable to afford food.
Financial factors limiting ability of patient/family to meet basic health needs: unable to afford medical expenses not covered by insurance/Medicare (e.g., co-payments).
Financial factors limiting ability of patient/family to meet basic health needs: unable to afford medicine or medical supplies.
Financial factors limiting ability of patient/family to meet basic health needs: none.
Financial factors limiting ability of patient/family to meet basic health needs: other (specify).
Financial factors limiting ability of patient/family to meet basic health needs: Rent/Utilities
From which of the following inpatient facilities was the patient discharged during the past 14 days: Hospital.
From which of the following inpatient facilities was the patient discharged during the past 14 days: Nursing home.
From which of the following inpatient facilities was the patient discharged during the past 14 days: Other (specify).
From which of the following inpatient facilities was the patient discharged during the past 14 days: Patient was not discharged from an inpatient facility.
From which of the following inpatient facilities was the patient discharged during the past 14 days: Rehabilitation facility.
Inpatient facility admitted from during past 14 days - hospital.
Inpatient facility admitted from during past 14 days - not discharged from an inpatient facility.
Inpatient facility admitted from during past 14 days - other.
Inpatient facility admitted from during past 14 days - other nursing home.
Inpatient facility admitted from during past 14 days - rehabilitation facility.
Inpatient facility admitted from during past 14 days - skilled nursing facility.
Inpatient discharge date (most recent).
Inpatient discharge date (most recent): unknown.
Inpatient diagnosis and ICD code categories: inpatient facility diagnosis, ICD Code - a.
Inpatient diagnosis and ICD code categories: inpatient facility diagnosis, ICD Code - b.
Medical treatment regimen change within past 14 days.
List patient's medical diagnosis and ICD code categories (three digits required; five optional), ICD - a.
List patient's medical diagnosis and ICD code categories (three digits required; five optional), ICD - b.
List patient's medical diagnosis and ICD code categories (three digits required; five optional), ICD - c.
List patient's medical diagnosis and ICD code categories (three digits required; five optional), ICD - d.
Conditions prior to medical or treatment regimen change or inpatient stay within past 14 days: disruptive or socially inappropriate behavior.
Conditions prior to medical or treatment regimen change or inpatient stay within past 14 days: impaired decision making.
Conditions prior to medical or treatment regimen change or inpatient stay within past 14 days: indwelling/suprapubic catheter.
Conditions prior to medical or treatment regimen change or inpatient stay within past 4 days: intractable pain.
Conditions prior to medical or treatment regimen change or inpatient stay within past 14 days: memory loss to the extent that supervision is required.
Conditions prior to medical or treatment regimen change or inpatient stay within past 14 days: no inpatient facility discharge and no change in medical or treatment regimen in past 14 days.
Conditions prior to medical or treatment regimen change or inpatient stay within past 14 days: none of the above.
Conditions prior to medical or treatment regimen change or inpatient stay within past 14 days: unknown.