Please select the eligibility criteria that correspond to the clinical trial below.
Title: Community Health Worker Support to Help Patients Control Chronic Disease
Brief Summary: The purpose of this proposal is to compare the effectiveness of community health worker (CHW) support vs. usual primary care for helping chronically-ill, low-SES patients to improve control of chronic conditions. Upon enrollment each patient will select one of their multiple chronic conditions as a focus for the trial and work with his/her PCP to set a chronic disease management goal. Patients are then randomized to receive usual primary care vs. CHW support for moving towards that goal.


Options:
A: Inclusion Criteria:

* Over 65
* Insured by KPMAG, USFHP/TRICARE, or Medicare FFS
* High likelihood of use of services in the coming year based on predictive modeling using current year's health care expenses

Exclusion Criteria:

* Moving out of area
* Currently assigned to case manager/in case management program
* Cognitive impairment and no legal representative
B: Inclusion Criteria:

* Age ≥18 years old.
* High complexity: according to a combined criteria a) predictive model of Valencia La Fe Health department for hospital resources consumption in next 12 months (probability \>95%) and b) risk confirmation by a clinical team with experience on chronic patients management.
* Participants that accept to participate in the study by the informed consent signature
* Participants that don't meet any of the exclusion criteria

Exclusion Criteria:

* Age \<18 años.
* Participants with cognitive or sensorial difficulties or with insufficient knowledge of one of the 2 official languages of Valencian Community that, according to the healthcare professional, may affect their study participation.
* No residents or temporary residents in the Health Department
* Homeless or participants with high-risk of social exclusion.
* Terminal patients or in palliative care according to the SECPAL (Spanish Society of Palliative Care) criteria .
* Community-dwelling patients
* Inability for mobile phone management if there is a caregiver with this capability.
* Participants without a phone line
* Non high-complexity chronic patients according to the recruitment healthcare professional.
* Members of the research team, workers related to the centers implied in the study or any other person directly involved in the study -
* First degree consanguinity or similar affinity with the team members.
* Participants already involved in case management.
* Participants already participating in clinical trials or experimental trials.
* Participants that don't accept to participate in the study or not signing the informed consent
* Participants with a main diagnostic of mental diseases
* Participants with active oncological diagnosis
* Participants already following specific interventions for hemodialysis, organ transplanting, day hospital
* Participants with an infectious chronic disease as unique chronic disease (HIV, BHV (Hepatitis B Virus)...)
C: Inclusion Criteria:

* Patient of target practices for at least 1 yr defined as having one office visit within preceding 12 month
* Home ZIP code including ANY of the following: 1. 19104 2. 19131 3. 19139 4. 19143 5. 19146
* 2 or more of the following conditions: 1. Obesity (BMI greater than 30), 2. HTN (ICD9 relating to HTN in EMR), 3. DM (ICD9 relating to DM in EMR), 4. Asthma/COPD and tobacco dependence (ICD9 for asthma or COPD in EMR AND documentation of tobacco use)
* Uninsured, insured by Medicaid or dually eligible for Medicaid/Managed Medicare
* Patients who have scheduled appointments in the future.

Exclusion Criteria:

* Will not provide informed consent for this study.
* Does not have the capacity to provide informed consent for this study.
* Previously enrolled in this study
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: C