Please select the eligibility criteria that correspond to the clinical trial below.
Title: Effect of a Longitudinal, Multifactorial Community-based Nursing Intervention on Mortality in Chronically Ill Older Adults
Brief Summary: Care coordination, disease management, geriatric care management, and preventive programs for chronically ill older adults vary in design and their impact on long-term health outcomes is not well established. This study investigates whether a community-based nursing intervention improves longevity and impact on cardiovascular risk factors in this population. The results reflect the impact of one of the study sites (Health Quality Partners) selected by the Centers for Medicare and Medicaid Services (CMS) to participate in the Medicare Coordinated Care Demonstration, a national demonstration designed to identify promising models of care coordination for chronically ill older adults. The study began in April 2002.


Options:
A: Inclusion Criteria:

African American men and women with documented coronary heart disease defined a coronary angiogram demonstrating the presence of one more coronary arteries with \> or = 50% stenosis.

Exclusion Criteria:

acute MI, stroke or coronary revascularization within the previous three months; symptomatic heart failure with EF \< 20%; dementia or other cognitive impairment determined clinically; and non-cardiac life threatening illness.

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B: Inclusion Criteria:

* Admitted with STEMI to a hospital in LHIN IV, coronary angiogram with and without PCI at Hamilton General Hospital during hospital admission

Exclusion Criteria:

* Non-english speaking
C: Inclusion Criteria:

* Admitted to Duke University Medical Center (DUMC) with both the diagnosis of acute MI (ICD code 410.01-410.91) and hypertension (ICD-9 code 401.X or clinical diagnosis)
* A cardiac catheterization at DUMC within the past 3 years
* Age \> 18 years
* Established or planned follow-up with a primary care/cardiology provider within the Duke University Health System or its Affiliated Clinics

Exclusion Criteria:

Medical Records Exclusion (occurs prior to mailing invitation):

* Diagnosis of metastatic cancer in the past 6 months
* Active diagnosis of psychosis or dementia
* Currently receiving hemodialysis
* Patients who have had a transplant

Patient-Level Exclusion (occurs at initial interview):

* Does not have access to a telephone
* Does not have access to a computer
* Refusal to provide informed consent
* Resident in nursing home or receiving home health care
* Severely impaired hearing or speech (patients must be able to respond to phone calls)
* Participating in another study (i.e., pharmaceutical trial)
* NYHA class IV heart failure
* Does not plan to have long-term follow-up with a primary care provider cardiologist
D: Inclusion Criteria:

* Aged 65 years and older
* Medicare Part A and B traditional, fee for service insurance coverage
* One or more of the following chronic conditions:
* Heart failure
* Coronary Disease
* Diabetes mellitus
* Asthma
* Hypertension
* Hypercholesterolemia
* A Geriatric Risk Stratification Level of 2 or more based on a pre-enrollment screening tool
* Geriatric Risk Stratification Level changed in Sep 2006 to a Level of 3 or more
* Willingness of the participant's primary care provider to collaborate

Exclusion Criteria:

* Amyotrophic lateral sclerosis
* Alzheimer's disease
* Dementia
* Diagnosis or history of cancer (other than skin) in the past 5 years
* End-stage renal disease
* Life expectancy on enrollment less than 6 months
* HIV or AIDS
* Huntington's disease
* Organ transplant candidate
* Psychosis or schizophrenia
* Resident of or imminent plan for long-term nursing home placement
* Seasonal relocation outside of the area for more than 4 weeks per year
* Anyone receiving service from Health Quality Partners in the past

Answer: D