Please select the eligibility criteria that correspond to the clinical trial below.
Title: Guided Care: Integrating High Tech and High Touch
Brief Summary: The purpose of the study is to evaluate the effect of a Guided Care nurse on the quality of the health and well-being of the frail elderly. A specially trained registered nurse will work closely with 1-3 primary care physicians to provide the most complex older patients (and their unpaid caregivers) with health care that is comprehensive, coordinated, patient-centered, and proactive. The study will evaluate the effects of Guided Care on:

* older persons' physical and mental health, health services utilization, quality of care, self-efficacy, and satisfaction with care;
* older persons' unpaid caregivers' burden; and
* primary care physicians' satisfaction with their care of chronically ill patients.


Options:
A: Inclusion Criteria:

* Veterans
* 60 years of age
* who have been seen in the General Medicine, Geriatrics, and Women's Clinics twice in the past year
* and have 2 or more serious or chronic medical conditions as determined by ICD-9 codes

Exclusion Criteria:

* Veterans will be excluded if they are:

  * deaf
  * blind
  * demented
B: Inclusion Criteria:

* General medical practices in NHS Fife and NHS Tayside with a compatible clinical IT system and agreeing to participate.
* Practices that agree to have relevant medication related data to be automatically extracted from their electronic clinical information systems from 1/10/10 to 30/9/13 (ie 12 months before first practice starts till 12 months after last practice starts).

Exclusion Criteria:

* Practices that use General Practice Administration System for Scotland (GPASS) or Egton Medicine Information System (EMIS) on the date of randomisation, since data extraction for the informatics requires Vision practice IT system.
C: 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
D: 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)...)

Answer: C