Please select the eligibility criteria that correspond to the clinical trial below.
Title: Continuum of Care, From the Emergency Ward to Living at Home - Implementation and Evaluation of an Intervention for Frail Elderly People
Brief Summary: The present study "Continuum of care for frail elderly people" form part of the research programme "Support for frail elderly persons - from prevention to palliation" (www.vardalinstitutet.net) which comprises research into three interventions. The program comprises interventions addressing frail elderly people in different phases of the disablement process, from elderly people who are beginning to develop frailty to very frail elderly people receiving palliative care.

The intervention "Continuum of care for frail elderly people" addresses elderly people who are frail and that have a great risk of high health care consumption. The hypothesis is that an intervention program for frail elderly people can reduce the number of visits to the emergency department, increase the life satisfaction and maintain the functional ability. The intervention, including an early geriatric assessment at the emergency department, early family support, a case manager in the community with a multi-professional team and active follow-up by the case manager, contributes to early recognition of the elderly people's need of information, care and rehabilitation and of informal caregivers' need of information. It enhances the transfer of information and integrates the care between different caregivers and different care levels, thereby better recognize frail elderly people's needs. Specifically, this study is expected to show that the intervention has a positive effect on the frail elderly person's functional ability, life satisfaction, satisfaction with health and social care, and health care consumption.


Options:
A: 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).
B: 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
C: 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
D: 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

Answer: C