Please select the eligibility criteria that correspond to the clinical trial below.
Title: Geriatric Resources for Assessment and Care of Elders
Brief Summary: The purpose of this study is to test the effectiveness of a collaborative model of team care as compared to usual care in improving functional outcomes among community-dwelling low-income older adults.


Options:
A: Inclusion Criteria:

* Frail community dwelling elderly patients aged 70 years or above. Frailty is determined with a two-phase screening instrument.

Exclusion Criteria:

* Non-frail elders
* Patients in palliative or end-of-life stages of disease
* Patients residing in long-term care facilities (care homes and nursing homes)
* Patients already enrolled in specific dementia-related case-management programmes who lack other health-related problems
* Patients not speaking or understanding the Dutch language
B: Inclusion Criteria:

* Patients followed by the home nursing service and primary care physician
* Over 60 years of age
* Able to give consent (patient or caregiver)
* Able to speak French
* Meeting frailty criteria as determined by one of the following alarms detected by the RAI-HC:
* Alarm 8: cognition
* Alarm 12: social role and function
* Alarm 15: falls
* Alarm 22: frailty of the informal care giver system.

Exclusion Criteria:

* Age under 60 years
* Unable (patient or caregiver) to give informed consent
* Unable to communicate adequately in French
* Patients' not receiving nursing visits (only receiving practical aid or services from occupational therapists).
C: Inclusion Criteria:

* 65 years old or older
* Annual income less than 200% of the federal poverty level
* Have had one or more primary care visits in the past 12 months
* Reside in the community (non-institutionalized)

Exclusion Criteria:

* Non-English speaking
* No regular access to a telephone
* Currently undergoing kidney dialysis treatments
* Residing with a patient already participating in the GRACE clinical trial
D: Inclusion Criteria:

* 70 years of age and over
* The patient lives independently or in a home for the aged
* The patient has a health problem that was recently presented to the GP by the patient or informal caregiver
* The request for help is related to the following problem fields: cognitive disorders, behavioral and psychological symptoms of dementia, mood disorders, mobility disorders and falling, or malnutrition
* The patient/informal caregiver and GP have determined a goal they want to achieve
* Fulfill one or more of these criteria: MMSE (Mini Mental State Examination) equal to or less than 26, GARS (Groningen Activity Restriction Scale) equal to or greater than 25 or MOS-20/subscale mental health equal to or less than 75

Exclusion Criteria:

* The problem or request for help has an acute nature, urging for action (medical or otherwise) within less than one week
* The problem or request for help is merely a medical diagnostic issue, urging for action only physicians (GP or specialist) can offer
* MMSE \< 20 or proved moderate to severe dementia (Clinical Dementia Rating scale \[CDR\] \> 1, 0) and no informal caregiver (no informal caregiver is defined as: no informal caregiver who meets the patient for at least once a week on average)
* The patient receives other forms of intermediate care or health care from a social worker or community-based geriatrician
* The patient is already on the waiting list for a nursing home because of the problem the patient is presented with in our study
* Predicted prognosis \< 6 months because of terminal illness

Answer: C