Super-utilizing patients with multiple chronic conditions tend to be both medically and socially complex. It is important to understand all barriers self-care including resources for medications and other medical supplies, social support, and mental health. It is also important to capture how well patients are managing their illnesses outside of the hospital.

The following assessments will provide a broad picture of patient assets and barriers upon entry to the program, and during the 45 day program period, and after any hospital readmissions.

Patient perception of experiences with the medical care system prior to program enrollment is important as well. Many patients do not know how to navigate the system and act as advocates for themselves. Also, many primary care physicians do not know how to effectively interact with complex patients. The following tool can be used to measure a change in patient perceptions before and after program implementation.

Patient Continuity of Care Questionnaire