Table 2 RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework

Reach: How do I reach the target population?

• Capture rate: proportion of patients interested in program participation out of those who are referred and appropriate at the time of discharge

• Show rate: proportion of patients who have a visit with the program out of those who are referred and appropriate at the time of discharge

Effectiveness: How do I know my intervention is effective?

• Absolute and observed/expected 30-day readmission rates as defined by CMS and reported as a routine quality metric by the healthcare system

Adoption: How do I develop organization support to deliver my intervention?

• Qualitative evaluation of program and participating primary care providers, which will be reported separately

Implementation: How do I ensure the intervention is delivered properly?

• Absolute and mean visit counts and visit type by month for the clinic as a whole and per patient

• Proportion of patients with a medicine reconciliation and provider visit in 72 h out of all participating patients

Maintenance: How do I incorporate the intervention so it is delivered over the long term?

• Institutional level: Reach, Effectiveness, and Implementation measures for 3 months after conclusion of trial

• Patient level: 90-day readmission and composite ED and hospitalization rates

• Patient level: Qualitative substudy evaluating effect of intervention more than 60 days after last contact