Please select the eligibility criteria that correspond to the clinical trial below.
Title: Health Care Hotspotting: A Randomized Controlled Trial
Brief Summary: This trial investigates the value created by the highly innovative Camden Coalition of Healthcare Providers' Care Management Program: Link2Care. The program targets "super-utilizers" of the health care system - specifically adults with 2 or more hospitalizations in the last six months 2 or more chronic conditions, and 5 or more outpatient medications - with intensive case management services. In particular, a team of nurses, social workers, community health workers and health coaches, supported by real-time data of healthcare utilization, perform home visits, accompany patients to doctor visits, and help patients enroll in social-service programs. This approach aims to improve the self-sufficiency of patients in navigating the healthcare and social-service systems and has the potential to reduce healthcare costs and improve patient health.


Options:
A: Inclusion Criteria:

* Usual medicine of five drugs or above
* Speak and understand Danish
* Admitted via the Acute Medicine Admission Ward
* Are able to give informed consent

Exclusion Criteria:

* Patients included in a similar study
* Declared terminal
* Suicidal
* In custody
* Isolated at the hospital
* Im- and/or expressive aphasia
* Severe dementia
B: 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
C: Inclusion Criteria:

* The investigators include patients who survived during hospitalisation with one of the following diagnoses according to coding of the International Classification of Diseases, 10th revision (ICD-10): unstable angina (I20.0), acute myocardial infarction (I21) or subsequent myocardial infarction (I22)

Exclusion Criteria:

* Have discharge diagnosis not unstable angina (I20.0), acute myocardial infarction (I21) and subsequent myocardial infarction (I22)
* Currently participate in another medication adherence study
* Discharge without prescription
* Unwilling to participate the study
* Unable to communicate in Vietnamese
* Unable to identify their own medications
* No telephone number
* Have cognitive impairment
D: Inclusion Criteria:

* In participating hospitals, all patients hospitalized with the most responsible diagnosis of Heart Failure

Exclusion Criteria:

* Patients who die during hospitalization or are transferred to another hospital

Answer: B