Please select the eligibility criteria that correspond to the clinical trial below.
Title: Support From Hospital to Home for Elders: A Randomized Controlled Study
Brief Summary: The investigators will randomize 700 non-psychiatric, non-obstetric, non-surgical patients aged 55 years and older at San Francisco General Hospital (SFGH) to usual care (ten days of prescription medication, discharge summary sent to primary care provider (PCP), and outpatient appt made for patient, and patient's nurse reviews discharge plan,) or usual care plus a peridischarge intervention (a visit with specialized in-hospital discharge nurse, development of personalized discharge plan, two phone calls from a nurse practitioner(NP)/physician assistant (PA) after discharge and availability of additional calls back from NP/PA, upon patient request, to help answer questions and assist patient's transition to outpatient care, and communication with primary care/subspecialty providers). The usual care and usual care plus intervention groups will be assessed for differences in mortality and rates of rehospitalization and emergency department use 30, 90 and 180 days following discharge from the hospital.

The discharge process from the hospital to home is frequently marked by poor quality and high risk of adverse events and readmissions. It has been hypothesized that better coordinated care, personalized patient education, and follow-up calls to identify potential sources of adverse events, such as medical complications and medication errors can reduce rehospitalization and emergency room visits following discharge from the hospital. Although these interventions have been shown to reduce combined hospital readmissions and emergency department visits in English-speaking patients, none has focused on elderly patients in a diverse urban public hospital setting that includes non-English-speakers, who might benefit more than other populations from enhanced services during and after discharge from the hospital. Further, these labor-intensive interventions are costly to implement, and it is unknown whether opportunity cost of providing additional services in a limited-resource environment such as San Francisco General Hospital (SFGH) outweighs the unknown clinical benefits.


Options:
A: Inclusion Criteria:

Patients must satisfy the following criteria based on the records from the index event:

* Is currently admitted to Cooper or Lourdes hospitals (still in hospital for recruitment)
* Resides in the following zip codes: 08101 (PO zip code), 08102-08105, 08107s, 08110
* Is 19-80 years old
* Has \>=2 hospital admissions in the past 6 months (to Camden area hospitals in the Health Information Exchange )
* Has \>=2 chronic conditions

Patients must meet at least three of the following criteria based largely on the electronic medical record:

* Has \>=5 outpatient medications
* Has difficulty accessing services
* Lacks social support
* Has mental health co-morbidity
* Is actively using drugs
* Is homeless

Exclusion Criteria:

* Already subject in RCT (treatment or control)
* Deceased or discharged prior to triage or recruitment
* Uninsured
* Cognitively impaired
* Oncology patient
* Index hospitalization is for: a surgical procedure for an acute problem, complications of a progressive chronic disease with limited treatments, or mental health issue only with no co-morbid conditions
B: Inclusion Criteria:

* According with the stroke diagnosis of Traditional Chinese Medicine
* According to atherosclerotic thrombotic cerebral infarction from Western diagnosis such as medical history and CT / MRI examinations
* It has attacked in 7 days
* The assessment of scale of NIHSS:4-24 points
* Age: ≥ 35 years and ≤ 75 years
* Patients or their legal guardians sign informed consent form

Exclusion Criteria:

* The patients with ICH or cerebral hemorrhage or TIA
* It has attacked beyond 7 days
* Patients with stroke history and the mRS ≥ 2 points before this attack
* Mixed type of stroke (infarction after bleeding or bleeding after infarction)
* Patients with cerebral infarction by cardiogenic embolism, blood hypercoagulable state and tunica intima exfoliating
* Patients with serious heart disease;failure of heart or liver or kidney; cancer;digestive tract bleeding
* Women of pregnancy or breast-feeding
* Patients who are taking part in other clinical trials that will influence the results of this study
C: Inclusion Criteria:

* patients over 18
* patients attending to the same CP for at least 3 months
* patients speaking french

Exclusion Criteria:

* patients with a length stay over 21 days (too many therapeutic modifications),
* patients who do not return to home,
* palliative patients and/or expected end of life
* patients that will not give their informed consent
D: Inclusion Criteria:

* patients age 55 and older
* admitted to the general medicine, family medicine, cardiology, and neurology services at San Francisco General Hospital,
* able to communicate in either English, Spanish, Mandarin or Cantonese,
* attending physicians agree to the patient's participation.
* Patients must be able to demonstrate an understanding of the study's goals through a set of teach back questions included in the consent process.

Exclusion Criteria:

* transferred from an outside hospital;
* admitted for a planned hospitalization (e.g. chemotherapy, a planned surgery)
* requiring hospice, nursing home, rehab or other institutional settings (i.e. expected by the physician team to be discharged to skilled nursing facilities) - those unable to independently consent (i.e. severely cognitively impaired, delirious, deaf, or involuntarily hospitalized because of severe mental illness)
* unable to understand English, Spanish or Cantonese (as reported by medical teams or unable to complete the consent teach-back process)
* less than age 55
* aphasic
* otherwise excluded by the medical team
* participated in the pilot project of this intervention.

Answer: D