Please select the eligibility criteria that correspond to the clinical trial below.
Title: Effect of a Longitudinal, Multifactorial Community-based Nursing Intervention on Mortality in Chronically Ill Older Adults
Brief Summary: Care coordination, disease management, geriatric care management, and preventive programs for chronically ill older adults vary in design and their impact on long-term health outcomes is not well established. This study investigates whether a community-based nursing intervention improves longevity and impact on cardiovascular risk factors in this population. The results reflect the impact of one of the study sites (Health Quality Partners) selected by the Centers for Medicare and Medicaid Services (CMS) to participate in the Medicare Coordinated Care Demonstration, a national demonstration designed to identify promising models of care coordination for chronically ill older adults. The study began in April 2002.


Options:
A: 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.
B: 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
C: 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
D: Inclusion Criteria:

* Diagnosis of diabetes and/or heart disease
* Poor disease control (defined as an HbA1c level of at least 8.5%, blood pressure greater than 140/90 mm Hg, LDL cholesterol greater than 130 mg/dL)
* Diagnosis of major depressive disorder

Exclusion Criteria:

* History of psychosis
* At high risk for suicide
* Cognitive impairment
* Current alcohol or substance abuse disorder
* Does not own a telephone
* Currently seeking psychiatric care
* Pregnant or breastfeeding
* Currently enrolled in a Group Health Cooperative disease management program
* Terminal illness
* Plans to leave Group Health Cooperative in less than a year
* Does not speak English

Answer: B