ALB and Renal insufficiency: In addition to the four predictors in LACE model, we identify 4 additional numerical predictors: Number of ER Encounters in Last Year, Number of Inpatient Encounters in Last Year, Braden Score, Polypharmacy, and 9 additional risk factors: Inpatient Encounters in Last Six Months, Not Employed, Discharge to Home Care or SNF, AMA, Albumin Level less than 3.4 g/dL, Leukemia, Malignancy, Renal Failure with Hemodialysis, or History of Alcohol Substance Abuse.