Please select the eligibility criteria that correspond to the clinical trial below.
Title: Effects of Strategies to Improve General Practitioner-nurse Collaboration and Communication in Regard to Hospital Admissions of Nursing Home Residents.
Brief Summary: Previously,six measures were developed for a better collaboration of general practitioners and nurses in nursing homes in a qualitative multistep bottom-up process. These measures, summarised as the interprof ACT intervention, shall improve the flow of information and the communication between the involved parties and lead to more transparency and effectiveness regarding treatment decisions of nursing home residents.The major aim of this trial is to examine the clinical effectiveness of interprof ACT. The main hypothesis is that implementation of interprof ACT reduces the cumulative incidence of hospitalisations of nursing home residents within 12 months from 50% to 35% (15% absolute reduction).


Options:
A: Inclusion Criteria:

* LTC facility must be located within the Toronto Central or Central LHIN geographic boundaries.
* LTC facility must be \<100 km from the St. Michael's Hospital wound care team.
* LTC facility must be entering data into MDS.
* LTC facility administrator must consent to participate.
* LTC facility must report a PU prevalence rate \>5.5% in the 4th quarter 2009 MDS. \[This is the average pressure ulcer prevalence rate for Ontario LTC facilities as reported by the Canadian Institute of Health Information (CIHI) in the 4th quarter 2009.\]
* Individual with PU (or Substitute Decision Maker (SDM)) must provide informed consent.

Exclusion Criteria:

* LTC facility \<100 beds.
* LTC facility \>100 km from the St. Michael's Hospital wound care team
* LTC facility reporting a PU prevalence rate \< 5.5% in the 4th quarter 2009 MDS.
B: Inclusion criteria for nursing homes:

* located in East Flanders
* size: \> 100 beds
* mixed population of high care dependent and low care-dependent residents with and without dementia
* software of Care Solutions or Farmad is used for electronic handling of the medication chart
* the NH management as well as the responsible CRA and the community pharmacist who delivers the medication in the NH give their written agreement to participate

Inclusion criteria for residents:

All residents of all wards of the participating nursing homes will be considered for inclusion if they meet the following inclusion criteria:

* aged 65 years or older
* mentally fit as well as cognitive impaired NH residents will be included after Informed Consent given by the resident (mentally capable residents) or his representative (cognitive impaired residents, defined as a sumscore of 6 or more on the KATZ items of disorientation in time and place).

Exclusion criteria for residents

Residents will not be considered for inclusion if:

* they have a limited life-expectancy (less than 3 months, as judged and documented by the treating GP)
* they are residing in a short-stay / revalidation bed
* GP refused to have his NH residents included in this pilot
C: Inclusion Criteria:

* patient aged 65 or more, with a dementia diagnosed by a specialist or the general practitioner;
* patient presenting with a disruptive NPS as defined in French Haute Autorité de Santé (HAS) recommendations (2009), that requires a specialist consultation based on the LTCF staff judgment;
* informed and written consent by the patient or the legal representative or the reliable person when appropriate;
* general practitioner agreement.

Exclusion Criteria:

* patient's life expectancy less than 6 months;
* Non agreement of study participation of patients or legal representative or the reliable person when appropriate.
D: Inclusion Criteria Residents:

* at least one GP visit in recent three months or
* two GP visits in recent 6 months or
* admission to the nursing home during the precedent 6 months independently of documented GP contacts
* at least 18 years of age
* written informed consent by the resident or her/his legal guardian

Inclusion Criteria Nursing Homes:

* minimum size of 40 residents
* written consent provided by the nursing home Manager Prior to randomisation

Exclusion Criteria Residents:

- admission for short term care only

Exclusion Criteria Nursing Homes:

- participation in other projects on interprofessional collaboration.

Answer: D