Please select the eligibility criteria that correspond to the clinical trial below.
Title: Preventive Primary Care Outreach for High Risk Older Persons
Brief Summary: It is recognized that a significant proportion of seniors over 75 years of age are at risk of functional decline, and thus of institutionalization and death. The investigators at McMaster University Medical Centre, are conducting is a randomized controlled trial of a preventive primary care outreach (PPCO) service provided to high risk seniors living in the community. The goal of this service is to identify unrecognized problems and individuals at increased risk and to link individuals to care. This preventive primary care service is provided by nurse case managers. The investigators have recruited patients through their family physicians who work in primary care networks. The investigators are screening all seniors aged 75 and over within these practices. The sample includes seniors aged 75 and over who are identified to be at risk according to the Sherbrooke Postal Questionnaire. Patients are randomly allocated to intervention and control groups. A research assistant, who is blind to group allocation, will collect data from seniors at baseline, six months, and at the end of one year.

Outcome measures include health-related quality of life (quality adjusted life years \[QALYs\]), health and social service utilization and costs, mortality, institutionalization, functional status, and perceived health status.

Primary Hypothesis:

The intervention compared to usual care will result in higher health-related quality of life.

Secondary Hypotheses:

Compared to usual care, the PPCO intervention will result in:

* the same or lower costs associated with service utilization;
* less functional decline;
* reduced mortality;
* lower rates of institutionalization; and
* better self-rated health.


Options:
A: Inclusion Criteria:

* Patient is 75 years of age and older
* Patient is listed on the roster of a participating family physician practice
* Patient resides in the Hamilton, Ontario, Canada area
* Patient or proxy able to answer questions in English

Exclusion Criteria:

* Principal residence is nursing home or long term care facility
* Patient is identified by family physician as palliative
* Patient currently receives home care services through the Community Care Access Centre
* Patient is a 'snowbird' and out of town for more than four weeks in any year
* Patient is scheduled for major elective surgery in the next year
B: Inclusion Criteria:

* 80 years and older or 65 to 79 years and having at least one chronic disease and being dependent in at least one activity of daily living

Exclusion Criteria:

* acute severely sick who immediately needs the assessment of a physician (within ten minutes)
* those with diagnosis of dementia (or severe cognitive impairment)
* patients in palliative care
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:

* 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).

Answer: A