Eligibility and Recruitment
mental illness, end-stage liver disease, cognitive impairment, diabetes, congestive heart failure, aphasia or hearing impairment
DISORDER, METASTATIC CANCER
Patients were eligible if they spoke English, were aged at least 18 years, had 1 or more hospitalizations in the prior 6 months, and had 2 or more chronic medical conditions (eg, uncontrolled diabetes, congestive heart failure, or end-stage liver disease) or a chronic condition and a substance use disorder or mental illness. Patients were excluded from participation if they were unable to consent due to cognitive impairment (ie, unable to “teach back” consent) or uncontrolled mental illness, had a diagnosis of metastatic cancer or less than 6 months to live, or were unable to participate as a result of aphasia or hearing impairment (eAppendix 2 in 