sdoh_hrsn.json

{
  "name": "SDoH HRSN",
  "remarks": [
    "Social Determinants of Health (SDoH) Health Related Social Needs (HRSN) screening."
  ],
  "states": {
    "Initial": {
      "type": "Initial",
      "direct_transition": "Assessment",
      "name": "Initial"
    },
    "Terminal": {
      "type": "Terminal",
      "name": "Terminal"
    },
    "Assessment": {
      "type": "Procedure",
      "codes": [
        {
          "system": "SNOMED-CT",
          "code": 710824005,
          "display": "Assessment of health and social care needs (procedure)",
          "value_set": ""
        }
      ],
      "distribution": {
        "kind": "UNIFORM",
        "parameters": {
          "high": 60,
          "low": 30
        }
      },
      "unit": "minutes",
      "direct_transition": "Q1",
      "name": "Assessment"
    },
    "PRAPARE": {
      "type": "MultiObservation",
      "category": "survey",
      "number_of_observations": 0,
      "codes": [
        {
          "system": "LOINC",
          "code": "93025-5",
          "display": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]",
          "value_set": ""
        }
      ],
      "direct_transition": "Terminal",
      "observations": [
        {
          "category": "survey",
          "unit": "",
          "codes": [
            {
              "system": "LOINC",
              "code": "56051-6",
              "display": "Do you consider yourself Hispanic/Latino?"
            }
          ],
          "attribute": "prapare_a1"
        },
        {
          "category": "survey",
          "unit": "",
          "codes": [
            {
              "system": "LOINC",
              "code": "32624-9",
              "display": "Race"
            }
          ],
          "attribute": "prapare_a2"
        },
        {
          "category": "survey",
          "unit": "",
          "codes": [
            {
              "system": "LOINC",
              "code": "93035-4",
              "display": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?"
            }
          ],
          "attribute": "prapare_a3"
        },
        {
          "category": "survey",
          "unit": "",
          "codes": [
            {
              "system": "LOINC",
              "code": "93034-7",
              "display": "Have you been discharged from the armed forces of the United States?"
            }
          ],
          "attribute": "prapare_a4"
        },
        {
          "category": "survey",
          "unit": "",
          "codes": [
            {
              "system": "LOINC",
              "code": "54899-0",
              "display": "Preferred language"
            }
          ],
          "attribute": "prapare_a5"
        },
        {
          "category": "survey",
          "unit": "{#}",
          "codes": [
            {
              "system": "LOINC",
              "code": "63512-8",
              "display": "How many people are living or staying at this address?"
            }
          ],
          "attribute": "household_size"
        },
        {
          "category": "survey",
          "unit": "",
          "codes": [
            {
              "system": "LOINC",
              "code": "71802-3",
              "display": "Housing status"
            }
          ],
          "attribute": "prapare_a7"
        },
        {
          "category": "survey",
          "unit": "",
          "codes": [
            {
              "system": "LOINC",
              "code": "93033-9",
              "display": "Are you worried about losing your housing?"
            }
          ],
          "attribute": "prapare_a8"
        },
        {
          "category": "survey",
          "unit": "",
          "codes": [
            {
              "system": "LOINC",
              "code": "56799-0",
              "display": "Address"
            }
          ],
          "attribute": "address"
        },
        {
          "category": "survey",
          "unit": "",
          "codes": [
            {
              "system": "LOINC",
              "code": "82589-3",
              "display": "Highest level of education"
            }
          ],
          "attribute": "prapare_a10"
        },
        {
          "category": "survey",
          "unit": "",
          "codes": [
            {
              "system": "LOINC",
              "code": "67875-5",
              "display": "Employment status - current"
            }
          ],
          "attribute": "prapare_a11"
        },
        {
          "category": "survey",
          "unit": "",
          "codes": [
            {
              "system": "LOINC",
              "code": "76437-3",
              "display": "Primary insurance"
            }
          ],
          "attribute": "prapare_a12"
        },
        {
          "category": "survey",
          "unit": "/a",
          "codes": [
            {
              "system": "LOINC",
              "code": "63586-2",
              "display": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?"
            }
          ],
          "attribute": "income"
        },
        {
          "category": "survey",
          "unit": "",
          "codes": [
            {
              "system": "LOINC",
              "code": "93031-3",
              "display": "In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?"
            }
          ],
          "attribute": "prapare_a14"
        },
        {
          "category": "survey",
          "unit": "",
          "codes": [
            {
              "system": "LOINC",
              "code": "93030-5",
              "display": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living"
            }
          ],
          "attribute": "prapare_a15"
        },
        {
          "category": "survey",
          "unit": "",
          "codes": [
            {
              "system": "LOINC",
              "code": "93029-7",
              "display": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?"
            }
          ],
          "attribute": "prapare_a16"
        },
        {
          "category": "survey",
          "unit": "",
          "codes": [
            {
              "system": "LOINC",
              "code": "93038-8",
              "display": "Stress level"
            }
          ],
          "attribute": "prapare_a17"
        },
        {
          "category": "survey",
          "unit": "",
          "codes": [
            {
              "system": "LOINC",
              "code": "93028-9",
              "display": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?"
            }
          ],
          "attribute": "prapare_a18"
        },
        {
          "category": "survey",
          "unit": "",
          "codes": [
            {
              "system": "LOINC",
              "code": "93027-1",
              "display": "Are you a refugee?"
            }
          ],
          "attribute": "prapare_a19"
        },
        {
          "category": "survey",
          "unit": "",
          "codes": [
            {
              "system": "LOINC",
              "code": "93026-3",
              "display": "Do you feel physically and emotionally safe where you currently live?"
            }
          ],
          "attribute": "prapare_a20"
        },
        {
          "category": "survey",
          "unit": "",
          "codes": [
            {
              "system": "LOINC",
              "code": "76501-6",
              "display": "Within the last year, have you been afraid of your partner or ex-partner?"
            }
          ],
          "attribute": "prapare_a21"
        }
      ],
      "name": "PRAPARE"
    },
    "Q1": {
      "type": "Simple",
      "complex_transition": [
        {
          "condition": {
            "condition_type": "Race",
            "race": "Hispanic"
          },
          "distributions": [],
          "transition": "A1_Yes"
        },
        {
          "distributions": [
            {
              "transition": "A1_No",
              "distribution": 0.995
            },
            {
              "transition": "A1_NotAnswer",
              "distribution": 0.005
            }
          ]
        }
      ],
      "name": "Q1"
    },
    "A1_Yes": {
      "type": "SetAttribute",
      "attribute": "prapare_a1",
      "direct_transition": "Q2",
      "value_code": {
        "system": "LOINC",
        "code": "LA33-6",
        "display": "Yes"
      },
      "name": "A1_Yes"
    },
    "A1_No": {
      "type": "SetAttribute",
      "attribute": "prapare_a1",
      "value_code": {
        "system": "LOINC",
        "code": "LA32-8",
        "display": "No"
      },
      "direct_transition": "Q2",
      "name": "A1_No"
    },
    "A1_NotAnswer": {
      "type": "SetAttribute",
      "attribute": "prapare_a1",
      "value_code": {
        "system": "LOINC",
        "code": "LA30122-8",
        "display": "I choose not to answer this question"
      },
      "direct_transition": "Q2",
      "name": "A1_NotAnswer"
    },
    "Q2": {
      "type": "Simple",
      "distributed_transition": [
        {
          "transition": "A2_NotAnswer",
          "distribution": 0.005
        },
        {
          "transition": "Q2A",
          "distribution": 0.995
        }
      ],
      "name": "Q2"
    },
    "Q3": {
      "type": "Simple",
      "conditional_transition": [
        {
          "transition": "Q3Y",
          "condition": {
            "condition_type": "Attribute",
            "attribute": "income",
            "operator": "<=",
            "value": 25000
          }
        },
        {
          "transition": "Q3N"
        }
      ],
      "name": "Q3"
    },
    "A2_Asian": {
      "type": "SetAttribute",
      "attribute": "prapare_a2",
      "value_code": {
        "system": "LOINC",
        "code": "LA6156-9",
        "display": "Asian"
      },
      "direct_transition": "Q3",
      "name": "A2_Asian"
    },
    "A2_Hawaiian": {
      "type": "SetAttribute",
      "attribute": "prapare_a2",
      "value_code": {
        "system": "LOINC",
        "code": "LA14045-1",
        "display": "Native Hawaiian"
      },
      "direct_transition": "Q3",
      "name": "A2_Hawaiian"
    },
    "A2_PacificIslander": {
      "type": "SetAttribute",
      "attribute": "prapare_a2",
      "value_code": {
        "system": "LOINC",
        "code": "LA30187-1",
        "display": "Pacific Islander"
      },
      "direct_transition": "Q3",
      "name": "A2_PacificIslander"
    },
    "A2_Black": {
      "type": "SetAttribute",
      "attribute": "prapare_a2",
      "value_code": {
        "system": "LOINC",
        "code": "LA14042-8",
        "display": "Black/African American"
      },
      "direct_transition": "Q3",
      "name": "A2_Black"
    },
    "A2_White": {
      "type": "SetAttribute",
      "attribute": "prapare_a2",
      "value_code": {
        "system": "LOINC",
        "code": "LA4457-3",
        "display": "White"
      },
      "direct_transition": "Q3",
      "name": "A2_White"
    },
    "A2_NativeAmerican": {
      "type": "SetAttribute",
      "attribute": "prapare_a2",
      "value_code": {
        "system": "LOINC",
        "code": "LA4-4",
        "display": "American Indian/Alaskan Native"
      },
      "direct_transition": "Q3",
      "name": "A2_NativeAmerican"
    },
    "A2_Other": {
      "type": "SetAttribute",
      "attribute": "prapare_a2",
      "value_code": {
        "system": "LOINC",
        "code": "LA46-8",
        "display": "Other"
      },
      "direct_transition": "Q3",
      "name": "A2_Other"
    },
    "A2_NotAnswer": {
      "type": "SetAttribute",
      "attribute": "prapare_a2",
      "value_code": {
        "system": "LOINC",
        "code": "LA30122-8",
        "display": "I choose not to answer this question"
      },
      "direct_transition": "Q3",
      "name": "A2_NotAnswer"
    },
    "Q2A": {
      "type": "Simple",
      "conditional_transition": [
        {
          "transition": "A2_Asian",
          "condition": {
            "condition_type": "Race",
            "race": "Asian"
          }
        },
        {
          "transition": "A2_Black",
          "condition": {
            "condition_type": "Race",
            "race": "Black"
          }
        },
        {
          "transition": "A2_White",
          "condition": {
            "condition_type": "Race",
            "race": "White"
          }
        },
        {
          "transition": "A2_Hawaiian",
          "condition": {
            "condition_type": "And",
            "conditions": [
              {
                "condition_type": "Attribute",
                "attribute": "state",
                "operator": "==",
                "value": "Hawaii"
              },
              {
                "condition_type": "Race",
                "race": "Hawaiian"
              }
            ]
          }
        },
        {
          "transition": "A2_PacificIslander",
          "condition": {
            "condition_type": "Race",
            "race": "Hawaiian"
          }
        },
        {
          "transition": "A2_NativeAmerican",
          "condition": {
            "condition_type": "Race",
            "race": "Native"
          }
        },
        {
          "transition": "A2_Other"
        }
      ],
      "name": "Q2A"
    },
    "Q4": {
      "type": "Simple",
      "conditional_transition": [
        {
          "transition": "A4_Yes",
          "condition": {
            "condition_type": "Attribute",
            "attribute": "veteran",
            "operator": "is not nil"
          }
        },
        {
          "transition": "Q4N"
        }
      ],
      "name": "Q4"
    },
    "A3_Yes": {
      "type": "SetAttribute",
      "attribute": "prapare_a3",
      "value_code": {
        "system": "LOINC",
        "code": "LA33-6",
        "display": "Yes"
      },
      "distributed_transition": [
        {
          "transition": "Social Migrant",
          "distribution": 0.00174
        },
        {
          "transition": "Q4",
          "distribution": 0.9982599999999999
        }
      ],
      "name": "A3_Yes"
    },
    "A3_No": {
      "type": "SetAttribute",
      "attribute": "prapare_a3",
      "value_code": {
        "system": "LOINC",
        "code": "LA32-8",
        "display": "No"
      },
      "direct_transition": "End Migrant",
      "name": "A3_No"
    },
    "A3_NotAnswer": {
      "type": "SetAttribute",
      "attribute": "prapare_a3",
      "value_code": {
        "system": "LOINC",
        "code": "LA30122-8",
        "display": "I choose not to answer this question"
      },
      "direct_transition": "Q4",
      "name": "A3_NotAnswer"
    },
    "Q3N": {
      "type": "Simple",
      "distributed_transition": [
        {
          "transition": "A3_No",
          "distribution": 0.995
        },
        {
          "transition": "A3_NotAnswer",
          "distribution": 0.005
        }
      ],
      "name": "Q3N"
    },
    "Q3Y": {
      "type": "Simple",
      "complex_transition": [
        {
          "condition": {
            "condition_type": "Age",
            "operator": "<=",
            "quantity": 17,
            "unit": "years",
            "value": 0
          },
          "distributions": [
            {
              "transition": "A3_Yes",
              "distribution": 0.03
            },
            {
              "transition": "Q3N",
              "distribution": 0.97
            }
          ]
        },
        {
          "condition": {
            "condition_type": "Age",
            "operator": "<=",
            "quantity": 19,
            "unit": "years",
            "value": 0
          },
          "distributions": [
            {
              "transition": "A3_Yes",
              "distribution": 0.04
            },
            {
              "transition": "Q3N",
              "distribution": 0.96
            }
          ]
        },
        {
          "condition": {
            "condition_type": "Age",
            "operator": "<=",
            "quantity": 24,
            "unit": "years",
            "value": 0
          },
          "distributions": [
            {
              "transition": "A3_Yes",
              "distribution": 0.11
            },
            {
              "transition": "Q3N",
              "distribution": 0.89
            }
          ]
        },
        {
          "condition": {
            "condition_type": "Age",
            "operator": "<=",
            "quantity": 34,
            "unit": "years",
            "value": 0
          },
          "distributions": [
            {
              "transition": "A3_Yes",
              "distribution": 0.26
            },
            {
              "transition": "Q3N",
              "distribution": 0.74
            }
          ]
        },
        {
          "condition": {
            "condition_type": "Age",
            "operator": "<=",
            "quantity": 44,
            "unit": "years",
            "value": 0
          },
          "distributions": [
            {
              "transition": "A3_Yes",
              "distribution": 0.23
            },
            {
              "transition": "Q3N",
              "distribution": 0.77
            }
          ]
        },
        {
          "condition": {
            "condition_type": "Age",
            "operator": "<=",
            "quantity": 54,
            "unit": "years",
            "value": 0
          },
          "distributions": [
            {
              "transition": "A3_Yes",
              "distribution": 0.19
            },
            {
              "transition": "Q3N",
              "distribution": 0.81
            }
          ]
        },
        {
          "condition": {
            "condition_type": "Age",
            "operator": "<=",
            "quantity": 64,
            "unit": "years",
            "value": 0
          },
          "distributions": [
            {
              "transition": "A3_Yes",
              "distribution": 0.11
            },
            {
              "transition": "Q3N",
              "distribution": 0.89
            }
          ]
        },
        {
          "distributions": [
            {
              "transition": "A3_Yes",
              "distribution": 0.04
            },
            {
              "transition": "Q3N",
              "distribution": 0.96
            }
          ]
        }
      ],
      "name": "Q3Y"
    },
    "Social Migrant": {
      "type": "ConditionOnset",
      "codes": [
        {
          "system": "SNOMED-CT",
          "code": 160701002,
          "display": "Social migrant (finding)",
          "value_set": ""
        }
      ],
      "direct_transition": "Q4",
      "name": "Social Migrant"
    },
    "End Migrant": {
      "type": "ConditionEnd",
      "direct_transition": "Q4",
      "condition_onset": "Social Migrant",
      "name": "End Migrant"
    },
    "Q5": {
      "type": "Simple",
      "conditional_transition": [
        {
          "transition": "A5_NotAnswer",
          "condition": {
            "condition_type": "Attribute",
            "attribute": "first_language",
            "operator": "is nil"
          }
        },
        {
          "transition": "A5_English",
          "condition": {
            "condition_type": "Attribute",
            "attribute": "first_language",
            "operator": "==",
            "value": "english"
          }
        },
        {
          "transition": "A5_Other"
        }
      ],
      "name": "Q5"
    },
    "A4_Yes": {
      "type": "SetAttribute",
      "attribute": "prapare_a4",
      "value_code": {
        "system": "LOINC",
        "code": "LA33-6",
        "display": "Yes"
      },
      "direct_transition": "Veteran",
      "name": "A4_Yes"
    },
    "A4_No": {
      "type": "SetAttribute",
      "attribute": "prapare_a4",
      "value_code": {
        "system": "LOINC",
        "code": "LA32-8",
        "display": "No"
      },
      "direct_transition": "Q5",
      "name": "A4_No"
    },
    "A4_NotAnswer": {
      "type": "SetAttribute",
      "attribute": "prapare_a4",
      "value_code": {
        "system": "LOINC",
        "code": "LA30122-8",
        "display": "I choose not to answer this question"
      },
      "direct_transition": "Q5",
      "name": "A4_NotAnswer"
    },
    "Q4N": {
      "type": "Simple",
      "distributed_transition": [
        {
          "transition": "A4_NotAnswer",
          "distribution": 0.005
        },
        {
          "transition": "A4_No",
          "distribution": 0.995
        }
      ],
      "name": "Q4N"
    },
    "Veteran": {
      "type": "ConditionOnset",
      "codes": [
        {
          "system": "SNOMED-CT",
          "code": 224355006,
          "display": "Served in armed forces (finding)",
          "value_set": ""
        }
      ],
      "direct_transition": "Q5",
      "name": "Veteran"
    },
    "Q6": {
      "type": "Simple",
      "conditional_transition": [
        {
          "transition": "Household_Size",
          "condition": {
            "condition_type": "Attribute",
            "attribute": "household_size",
            "operator": "is nil"
          }
        },
        {
          "transition": "Q7"
        }
      ],
      "name": "Q6"
    },
    "A5_English": {
      "type": "SetAttribute",
      "attribute": "prapare_a5",
      "direct_transition": "Q6",
      "value_code": {
        "system": "LOINC",
        "code": "LA43-5",
        "display": "English"
      },
      "name": "A5_English"
    },
    "A5_Other": {
      "type": "SetAttribute",
      "attribute": "prapare_a5",
      "value_code": {
        "system": "LOINC",
        "code": "LA30188-9",
        "display": "Language other than English"
      },
      "direct_transition": "Q6",
      "name": "A5_Other"
    },
    "A5_NotAnswer": {
      "type": "SetAttribute",
      "attribute": "prapare_a5",
      "value_code": {
        "system": "LOINC",
        "code": "LA30122-8",
        "display": "I choose not to answer this question"
      },
      "direct_transition": "Q6",
      "name": "A5_NotAnswer"
    },
    "Q7": {
      "type": "Simple",
      "complex_transition": [
        {
          "condition": {
            "condition_type": "Attribute",
            "attribute": "homeless",
            "operator": "==",
            "value": true
          },
          "distributions": [],
          "transition": "A7_Homeless"
        },
        {
          "distributions": [
            {
              "transition": "A7_NotAnswer",
              "distribution": 0.005
            },
            {
              "transition": "A7_NotHomeless",
              "distribution": 0.995
            }
          ]
        }
      ],
      "name": "Q7"
    },
    "Household_Size": {
      "type": "SetAttribute",
      "attribute": "household_size",
      "direct_transition": "Q7",
      "distribution": {
        "kind": "UNIFORM",
        "round": true,
        "parameters": {
          "high": 8,
          "low": 1
        }
      },
      "name": "Household_Size"
    },
    "Q8": {
      "type": "Simple",
      "complex_transition": [
        {
          "condition": {
            "condition_type": "Attribute",
            "attribute": "severe_housing_cost_burden",
            "operator": "==",
            "value": true
          },
          "distributions": [],
          "transition": "A8_Yes"
        },
        {
          "distributions": [
            {
              "transition": "A8_NotAnswer",
              "distribution": 0.005
            },
            {
              "transition": "A8_No",
              "distribution": 0.995
            }
          ]
        }
      ],
      "name": "Q8"
    },
    "A7_Homeless": {
      "type": "SetAttribute",
      "attribute": "prapare_a7",
      "direct_transition": "Homeless",
      "value_code": {
        "system": "LOINC",
        "code": "LA30190-5",
        "display": "I do not have housing (staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, or in a park)"
      },
      "name": "A7_Homeless"
    },
    "A7_NotHomeless": {
      "type": "SetAttribute",
      "attribute": "prapare_a7",
      "value_code": {
        "system": "LOINC",
        "code": "LA30189-7",
        "display": "I have housing"
      },
      "direct_transition": "Not Homeless",
      "name": "A7_NotHomeless"
    },
    "A7_NotAnswer": {
      "type": "SetAttribute",
      "attribute": "prapare_a7",
      "value_code": {
        "system": "LOINC",
        "code": "LA30122-8",
        "display": "I choose not to answer this question"
      },
      "direct_transition": "Q8",
      "name": "A7_NotAnswer"
    },
    "Homeless": {
      "type": "ConditionOnset",
      "codes": [
        {
          "system": "SNOMED-CT",
          "code": 32911000,
          "display": "Homeless (finding)",
          "value_set": ""
        }
      ],
      "direct_transition": "Q8",
      "name": "Homeless"
    },
    "Not Homeless": {
      "type": "ConditionEnd",
      "direct_transition": "Q8",
      "codes": [
        {
          "system": "SNOMED-CT",
          "code": 32911000,
          "display": "Homeless (finding)",
          "value_set": ""
        }
      ],
      "name": "Not Homeless"
    },
    "A8_Yes": {
      "type": "SetAttribute",
      "attribute": "prapare_a8",
      "value_code": {
        "system": "LOINC",
        "code": "LA33-6",
        "display": "Yes"
      },
      "direct_transition": "Housing Issue",
      "name": "A8_Yes"
    },
    "A8_No": {
      "type": "SetAttribute",
      "attribute": "prapare_a8",
      "value_code": {
        "system": "LOINC",
        "code": "LA32-8",
        "display": "No"
      },
      "direct_transition": "End Housing Issue",
      "name": "A8_No"
    },
    "A8_NotAnswer": {
      "type": "SetAttribute",
      "attribute": "prapare_a8",
      "value_code": {
        "system": "LOINC",
        "code": "LA30122-8",
        "display": "I choose not to answer this question"
      },
      "direct_transition": "Q10",
      "name": "A8_NotAnswer"
    },
    "Housing Issue": {
      "type": "ConditionOnset",
      "codes": [
        {
          "system": "SNOMED-CT",
          "code": 105531004,
          "display": "Housing unsatisfactory (finding)",
          "value_set": ""
        }
      ],
      "direct_transition": "Q10",
      "name": "Housing Issue"
    },
    "End Housing Issue": {
      "type": "ConditionEnd",
      "direct_transition": "Q10",
      "condition_onset": "Housing Issue",
      "name": "End Housing Issue"
    },
    "Q10": {
      "type": "Simple",
      "distributed_transition": [
        {
          "transition": "Q10A",
          "distribution": 0.995
        },
        {
          "transition": "A10_NotAnswer",
          "distribution": 0.005
        }
      ],
      "name": "Q10"
    },
    "Q11": {
      "type": "Simple",
      "conditional_transition": [
        {
          "transition": "Check Unemployment Change",
          "condition": {
            "condition_type": "Attribute",
            "attribute": "unemployed",
            "operator": "==",
            "value": true
          }
        },
        {
          "transition": "Q11B"
        }
      ],
      "name": "Q11"
    },
    "A10_NotAnswer": {
      "type": "SetAttribute",
      "attribute": "prapare_a10",
      "value_code": {
        "system": "LOINC",
        "code": "LA30122-8",
        "display": "I choose not to answer this question"
      },
      "direct_transition": "Q11",
      "name": "A10_NotAnswer"
    },
    "A10C": {
      "type": "SetAttribute",
      "attribute": "prapare_a10",
      "value_code": {
        "system": "LOINC",
        "code": "LA30193-9",
        "display": "More than high school"
      },
      "direct_transition": "Education_Onset_2",
      "name": "A10C"
    },
    "A10B": {
      "type": "SetAttribute",
      "attribute": "prapare_a10",
      "value_code": {
        "system": "LOINC",
        "code": "LA30192-1",
        "display": "High school diploma or GED"
      },
      "direct_transition": "Education_Onset",
      "name": "A10B"
    },
    "A10A": {
      "type": "SetAttribute",
      "attribute": "prapare_a10",
      "direct_transition": "Education Onset",
      "value_code": {
        "system": "LOINC",
        "code": "LA30191-3",
        "display": "Less than high school degree"
      },
      "name": "A10A"
    },
    "Q10A": {
      "type": "Simple",
      "conditional_transition": [
        {
          "transition": "A10A",
          "condition": {
            "condition_type": "Attribute",
            "attribute": "education",
            "operator": "==",
            "value": "less_than_hs"
          }
        },
        {
          "transition": "A10B",
          "condition": {
            "condition_type": "Attribute",
            "attribute": "education",
            "operator": "==",
            "value": "hs_degree"
          }
        },
        {
          "transition": "A10C"
        }
      ],
      "name": "Q10A"
    },
    "Education Onset": {
      "type": "ConditionOnset",
      "assign_to_attribute": "education_condition",
      "codes": [
        {
          "system": "SNOMED-CT",
          "code": 224295006,
          "display": "Only received primary school education (finding)",
          "value_set": ""
        }
      ],
      "direct_transition": "Q11",
      "name": "Education Onset"
    },
    "Education_Onset": {
      "type": "ConditionOnset",
      "assign_to_attribute": "education_condition",
      "codes": [
        {
          "system": "SNOMED-CT",
          "code": 5251000175109,
          "display": "Received certificate of high school equivalency (finding)",
          "value_set": ""
        }
      ],
      "direct_transition": "Q11",
      "name": "Education_Onset"
    },
    "Education_Onset_2": {
      "type": "ConditionOnset",
      "assign_to_attribute": "education_condition",
      "codes": [
        {
          "system": "SNOMED-CT",
          "code": 224299000,
          "display": "Received higher education (finding)",
          "value_set": ""
        }
      ],
      "direct_transition": "Q11",
      "name": "Education_Onset_2"
    },
    "Q12": {
      "type": "Simple",
      "conditional_transition": [
        {
          "transition": "A12_NotAnswer",
          "condition": {
            "condition_type": "Attribute",
            "attribute": "insurance_status",
            "operator": "is nil"
          }
        },
        {
          "transition": "A12_None",
          "condition": {
            "condition_type": "Attribute",
            "attribute": "insurance_status",
            "operator": "==",
            "value": "none"
          }
        },
        {
          "transition": "A12_Medicaid",
          "condition": {
            "condition_type": "Attribute",
            "attribute": "insurance_status",
            "operator": "==",
            "value": "medicaid"
          }
        },
        {
          "transition": "A12_Medicare",
          "condition": {
            "condition_type": "Attribute",
            "attribute": "insurance_status",
            "operator": "==",
            "value": "medicare"
          }
        },
        {
          "transition": "A12_Private",
          "condition": {
            "condition_type": "Attribute",
            "attribute": "insurance_status",
            "operator": "==",
            "value": "private"
          }
        },
        {
          "transition": "A12_NotAnswer"
        }
      ],
      "name": "Q12"
    },
    "A11A": {
      "type": "SetAttribute",
      "attribute": "prapare_a11",
      "value_code": {
        "system": "LOINC",
        "code": "LA17956-6",
        "display": "Unemployed"
      },
      "direct_transition": "Unemployed",
      "name": "A11A"
    },
    "Q11B": {
      "type": "Simple",
      "distributed_transition": [
        {
          "transition": "Some Employment",
          "distribution": 0.995
        },
        {
          "transition": "A11_NotAnswer",
          "distribution": 0.005
        }
      ],
      "name": "Q11B"
    },
    "Unemployed": {
      "type": "ConditionOnset",
      "assign_to_attribute": "employment_condition",
      "codes": [
        {
          "system": "SNOMED-CT",
          "code": 73438004,
          "display": "Unemployed (finding)",
          "value_set": ""
        }
      ],
      "direct_transition": "Q12",
      "name": "Unemployed"
    },
    "A11_NotAnswer": {
      "type": "SetAttribute",
      "attribute": "prapare_a11",
      "value_code": {
        "system": "LOINC",
        "code": "LA30122-8",
        "display": "I choose not to answer this question"
      },
      "direct_transition": "Q12",
      "name": "A11_NotAnswer"
    },
    "A11B": {
      "type": "SetAttribute",
      "attribute": "prapare_a11",
      "value_code": {
        "system": "LOINC",
        "code": "LA30136-8",
        "display": "Full-time work"
      },
      "direct_transition": "Employed Full Time",
      "name": "A11B"
    },
    "A11C": {
      "type": "SetAttribute",
      "attribute": "prapare_a11",
      "value_code": {
        "system": "LOINC",
        "code": "LA30138-4",
        "display": "Part-time or temporary work"
      },
      "direct_transition": "Employed Part Time",
      "name": "A11C"
    },
    "A11D": {
      "type": "SetAttribute",
      "attribute": "prapare_a11",
      "value_code": {
        "system": "LOINC",
        "code": "LA30137-6",
        "display": "Otherwise unemployed but not seeking work (ex: student, retired, disabled, unpaid primary care giver)"
      },
      "direct_transition": "Employed Not",
      "name": "A11D"
    },
    "Employed Full Time": {
      "type": "ConditionOnset",
      "assign_to_attribute": "employment_condition",
      "codes": [
        {
          "system": "SNOMED-CT",
          "code": 160903007,
          "display": "Full-time employment (finding)",
          "value_set": ""
        }
      ],
      "direct_transition": "Q12",
      "name": "Employed Full Time"
    },
    "Employed Part Time": {
      "type": "ConditionOnset",
      "assign_to_attribute": "employment_condition",
      "codes": [
        {
          "system": "SNOMED-CT",
          "code": 160904001,
          "display": "Part-time employment (finding)",
          "value_set": ""
        }
      ],
      "direct_transition": "Q12",
      "name": "Employed Part Time"
    },
    "Employed Not": {
      "type": "ConditionOnset",
      "assign_to_attribute": "employment_condition",
      "codes": [
        {
          "system": "SNOMED-CT",
          "code": 741062008,
          "display": "Not in labor force (finding)",
          "value_set": ""
        }
      ],
      "direct_transition": "Q12",
      "name": "Employed Not"
    },
    "A12_NotAnswer": {
      "type": "SetAttribute",
      "attribute": "prapare_a12",
      "value_code": {
        "system": "LOINC",
        "code": "LA30122-8",
        "display": "I choose not to answer this question"
      },
      "direct_transition": "Q14",
      "name": "A12_NotAnswer"
    },
    "A12_None": {
      "type": "SetAttribute",
      "attribute": "prapare_a12",
      "value_code": {
        "system": "LOINC",
        "code": "LA30194-7",
        "display": "None/uninsured"
      },
      "direct_transition": "Q14",
      "name": "A12_None"
    },
    "A12_Medicaid": {
      "type": "SetAttribute",
      "attribute": "prapare_a12",
      "value_code": {
        "system": "LOINC",
        "code": "LA17849-3",
        "display": "Medicaid"
      },
      "direct_transition": "Q14",
      "name": "A12_Medicaid"
    },
    "A12_Medicare": {
      "type": "SetAttribute",
      "attribute": "prapare_a12",
      "value_code": {
        "system": "LOINC",
        "code": "LA15652-3",
        "display": "Medicare"
      },
      "direct_transition": "Q14",
      "name": "A12_Medicare"
    },
    "A12_Private": {
      "type": "SetAttribute",
      "attribute": "prapare_a12",
      "value_code": {
        "system": "LOINC",
        "code": "LA6350-8",
        "display": "Private insurance"
      },
      "direct_transition": "Q14",
      "name": "A12_Private"
    },
    "Q14": {
      "type": "Simple",
      "conditional_transition": [
        {
          "transition": "A14_NotAnswer",
          "condition": {
            "condition_type": "And",
            "conditions": [
              {
                "condition_type": "Attribute",
                "attribute": "food_insecurity",
                "operator": "is nil"
              },
              {
                "condition_type": "Attribute",
                "attribute": "poverty_ratio",
                "operator": "is nil"
              }
            ]
          }
        },
        {
          "transition": "Q14A"
        }
      ],
      "name": "Q14"
    },
    "Q15": {
      "type": "Simple",
      "complex_transition": [
        {
          "condition": {
            "condition_type": "Or",
            "conditions": [
              {
                "condition_type": "Attribute",
                "attribute": "no_vehicle_access",
                "operator": "is nil"
              },
              {
                "condition_type": "Attribute",
                "attribute": "no_vehicle_access",
                "operator": "==",
                "value": false
              }
            ]
          },
          "distributions": [],
          "transition": "A15_No"
        },
        {
          "distributions": [
            {
              "transition": "A15_YesA",
              "distribution": 0.5
            },
            {
              "transition": "A15_YesB",
              "distribution": 0.5
            }
          ]
        }
      ],
      "name": "Q15"
    },
    "A14_NotAnswer": {
      "type": "SetAttribute",
      "attribute": "prapare_a14",
      "value_code": {
        "system": "LOINC",
        "code": "LA30122-8",
        "display": "I choose not to answer this question"
      },
      "direct_transition": "Q15",
      "name": "A14_NotAnswer"
    },
    "Q14A": {
      "type": "Simple",
      "distributed_transition": [
        {
          "transition": "A14_NotAnswer",
          "distribution": 0.01
        },
        {
          "transition": "Q14B",
          "distribution": 0.99
        }
      ],
      "name": "Q14A"
    },
    "Q14B": {
      "type": "Simple",
      "conditional_transition": [
        {
          "transition": "A14_Food",
          "condition": {
            "condition_type": "Attribute",
            "attribute": "food_insecurity",
            "operator": "==",
            "value": true
          }
        },
        {
          "transition": "Q14C"
        }
      ],
      "name": "Q14B"
    },
    "A14_Food": {
      "type": "SetAttribute",
      "attribute": "prapare_a14",
      "value_code": {
        "system": "LOINC",
        "code": "LA30125-1",
        "display": "Food"
      },
      "direct_transition": "Q15",
      "name": "A14_Food"
    },
    "A14_Clothing": {
      "type": "SetAttribute",
      "attribute": "prapare_a14",
      "value_code": {
        "system": "LOINC",
        "code": "LA30126-9",
        "display": "Clothing"
      },
      "direct_transition": "Q15",
      "name": "A14_Clothing"
    },
    "A14_Utilities": {
      "type": "SetAttribute",
      "attribute": "prapare_a14",
      "value_code": {
        "system": "LOINC",
        "code": "LA30124-4",
        "display": "Utilities"
      },
      "direct_transition": "Q15",
      "name": "A14_Utilities"
    },
    "A14_Childcare": {
      "type": "SetAttribute",
      "attribute": "prapare_a14",
      "value_code": {
        "system": "LOINC",
        "code": "LA30127-7",
        "display": "Child care"
      },
      "direct_transition": "Q15",
      "name": "A14_Childcare"
    },
    "A14_Medicine": {
      "type": "SetAttribute",
      "attribute": "prapare_a14",
      "value_code": {
        "system": "LOINC",
        "code": "LA30128-5",
        "display": "Medicine or Any Health Care (Medical, Dental, Mental Health, Vision)"
      },
      "direct_transition": "Q15",
      "name": "A14_Medicine"
    },
    "A14_Phone": {
      "type": "SetAttribute",
      "attribute": "prapare_a14",
      "value_code": {
        "system": "LOINC",
        "code": "LA30129-3",
        "display": "Phone"
      },
      "direct_transition": "Q15",
      "name": "A14_Phone"
    },
    "A14_Other": {
      "type": "SetAttribute",
      "attribute": "prapare_a14",
      "value_code": {
        "system": "LOINC",
        "code": "LA46-8",
        "display": "Other"
      },
      "direct_transition": "Q15",
      "name": "A14_Other"
    },
    "Q14C": {
      "type": "Simple",
      "conditional_transition": [
        {
          "transition": "Q14_Half",
          "condition": {
            "condition_type": "Attribute",
            "attribute": "poverty_ratio",
            "operator": "<",
            "value": 0.5
          }
        },
        {
          "transition": "Q14_LessThanOne",
          "condition": {
            "condition_type": "Attribute",
            "attribute": "poverty_ratio",
            "operator": "<",
            "value": 1
          }
        },
        {
          "transition": "Q14_LessThanTwo",
          "condition": {
            "condition_type": "Attribute",
            "attribute": "poverty_ratio",
            "operator": "<",
            "value": 2
          }
        },
        {
          "transition": "Q14_LessThanFive",
          "condition": {
            "condition_type": "Attribute",
            "attribute": "poverty_ratio",
            "operator": "<",
            "value": 5
          }
        },
        {
          "transition": "Q14_FiveOrHigher"
        }
      ],
      "name": "Q14C"
    },
    "Q14_Half": {
      "type": "Simple",
      "distributed_transition": [
        {
          "transition": "A14_Medicine",
          "distribution": 0.227
        },
        {
          "transition": "Q14_Half_Food?",
          "distribution": 0.7729999999999999
        }
      ],
      "name": "Q14_Half"
    },
    "Q14_LessThanOne": {
      "type": "Simple",
      "direct_transition": "Q14_LessThanOne_Meds?",
      "name": "Q14_LessThanOne"
    },
    "Q14_LessThanTwo": {
      "type": "Simple",
      "distributed_transition": [
        {
          "transition": "A14_Medicine",
          "distribution": 0.196
        },
        {
          "transition": "Q14_LessThanTwo_Food?",
          "distribution": 0.804
        }
      ],
      "name": "Q14_LessThanTwo"
    },
    "Q14_LessThanFive": {
      "type": "Simple",
      "distributed_transition": [
        {
          "transition": "A14_Medicine",
          "distribution": 0.11
        },
        {
          "transition": "Q14_LessThanFive_Food?",
          "distribution": 0.89
        }
      ],
      "name": "Q14_LessThanFive"
    },
    "Q14_FiveOrHigher": {
      "type": "Simple",
      "distributed_transition": [
        {
          "transition": "A14_Medicine",
          "distribution": 0.043
        },
        {
          "transition": "Q14_FiveOrHigher_Food?",
          "distribution": 0.957
        }
      ],
      "name": "Q14_FiveOrHigher"
    },
    "Q14_Durables": {
      "type": "Simple",
      "distributed_transition": [
        {
          "transition": "A14_Childcare",
          "distribution": 0.25
        },
        {
          "transition": "A14_Phone",
          "distribution": 0.25
        },
        {
          "transition": "A14_Other",
          "distribution": 0.25
        },
        {
          "transition": "A14_Clothing",
          "distribution": 0.25
        }
      ],
      "name": "Q14_Durables"
    },
    "Q14_LessThanOne_Meds?": {
      "type": "Simple",
      "distributed_transition": [
        {
          "transition": "A14_Medicine",
          "distribution": 0.227
        },
        {
          "transition": "Q14_LessThanOne_Food?",
          "distribution": 0.773
        }
      ],
      "name": "Q14_LessThanOne_Meds?"
    },
    "Q14_LessThanOne_Food?": {
      "type": "Simple",
      "distributed_transition": [
        {
          "transition": "A14_Food",
          "distribution": 0.271
        },
        {
          "transition": "Q14_LessThanOne_Utils?",
          "distribution": 0.729
        }
      ],
      "name": "Q14_LessThanOne_Food?"
    },
    "Q14_LessThanOne_Utils?": {
      "type": "Simple",
      "distributed_transition": [
        {
          "transition": "A14_Utilities",
          "distribution": 0.325
        },
        {
          "transition": "Q14_LessThanOne_Durables?",
          "distribution": 0.675
        }
      ],
      "name": "Q14_LessThanOne_Utils?"
    },
    "Q14_LessThanOne_Durables?": {
      "type": "Simple",
      "distributed_transition": [
        {
          "transition": "Q14_Durables",
          "distribution": 0.325
        },
        {
          "transition": "A14_NotAnswer",
          "distribution": 0.675
        }
      ],
      "name": "Q14_LessThanOne_Durables?"
    },
    "Q14_LessThanTwo_Food?": {
      "type": "Simple",
      "distributed_transition": [
        {
          "transition": "A14_Food",
          "distribution": 0.185
        },
        {
          "transition": "Q14_LessThanTwo_Utils?",
          "distribution": 0.815
        }
      ],
      "name": "Q14_LessThanTwo_Food?"
    },
    "Q14_LessThanTwo_Utils?": {
      "type": "Simple",
      "distributed_transition": [
        {
          "transition": "A14_Utilities",
          "distribution": 0.223
        },
        {
          "transition": "Q14_LessThanTwo_Durables?",
          "distribution": 0.777
        }
      ],
      "name": "Q14_LessThanTwo_Utils?"
    },
    "Q14_LessThanTwo_Durables?": {
      "type": "Simple",
      "distributed_transition": [
        {
          "transition": "Q14_Durables",
          "distribution": 0.216
        },
        {
          "transition": "A14_NotAnswer",
          "distribution": 0.784
        }
      ],
      "name": "Q14_LessThanTwo_Durables?"
    },
    "Q14_Half_Food?": {
      "type": "Simple",
      "distributed_transition": [
        {
          "transition": "A14_Food",
          "distribution": 0.266
        },
        {
          "transition": "Q14_Half_Utils?",
          "distribution": 0.734
        }
      ],
      "name": "Q14_Half_Food?"
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      "referenced_by_attribute": "employment_condition",
      "direct_transition": "A11B"
    },
    "Check Otherwise Work Change": {
      "type": "Simple",
      "name": "Check Otherwise Work Change",
      "conditional_transition": [
        {
          "transition": "Q12",
          "condition": {
            "condition_type": "Active Condition",
            "codes": [
              {
                "system": "SNOMED-CT",
                "code": 741062008,
                "display": "Not in labor force (finding)"
              }
            ]
          }
        },
        {
          "transition": "A11D",
          "condition": {
            "condition_type": "Attribute",
            "attribute": "employment_condition",
            "operator": "is nil"
          }
        },
        {
          "transition": "Start Change to Not in Labor Force"
        }
      ]
    },
    "Start Change to Not in Labor Force": {
      "type": "ConditionEnd",
      "direct_transition": "A11D",
      "name": "Start Change to Not in Labor Force",
      "referenced_by_attribute": "employment_condition"
    },
    "Check Unemployment Change": {
      "type": "Simple",
      "name": "Check Unemployment Change",
      "conditional_transition": [
        {
          "transition": "Q12",
          "condition": {
            "condition_type": "Active Condition",
            "codes": [
              {
                "system": "SNOMED-CT",
                "code": 73438004,
                "display": "Unemployed (finding)"
              }
            ]
          }
        },
        {
          "transition": "A11A",
          "condition": {
            "condition_type": "Attribute",
            "attribute": "employment_condition",
            "operator": "is nil"
          }
        },
        {
          "transition": "Start Change to Unemployed"
        }
      ]
    },
    "Start Change to Unemployed": {
      "type": "ConditionEnd",
      "direct_transition": "A11A",
      "name": "Start Change to Unemployed",
      "referenced_by_attribute": "employment_condition"
    }
  },
  "gmf_version": 2
}