Please select the eligibility criteria that correspond to the clinical trial below.
Title: Compared Efficacy of Nurse-led and GP-led Geriatric Assessment in PrImary Care: A Pragmatic Three-arm Cluster Randomized Controlled Trial
Brief Summary: Older patients account for around 10% of the population, of which 57% have a long-term illness, and 33% were admitted in the past year.

Geriatric assessment (GA) is a multidimensional assessment of general health status that can help identifying deficiencies and followed by a personalized care plan.

Assessment and management of elderly patients is a daily concern for the general practitioner (GP) but conflicting results have been reported so far relating to the clinical impact of GA when applied in the primary care setting.

This study protocol aims to assess the effect on morbi-mortality of a complex intervention in patients aged ≥70 years with chronic conditions in primary care. It aims to demonstrate that a GA adapted to primary care, followed by a personalized care plan and combined with successful interprofessional collaboration can improve clinically relevant outcomes in elderly patients with chronic conditions such as one-year overall mortality, unplanned hospital admission, emergency visits, or institutionalization.

The CEPIA study will also help addressing the issue of whether an improved benefit could be achieved from a systematic nurse-led or a case-by-case GP-led GA.


Options:
A: Inclusion Criteria:

* Established patients
* Men ages 35-79
* Women ages 45-79
* History of CVD (100 participants)
* CHD risk equal or greater than 10%
* elevated CHD risk factor

Exclusion Criteria:

* non-English speaking
* no phone
* treatment of psychosis
* history of alcohol/substance abuse within last 2 years
* pregnancy, breast feeding, or anticipated pregnancy in next 18 months
* history of malignancy, other than non-melanoma skin cancer, that has not been in remission or cured surgically for \>5 years
* recent history (in past year) of hypoglycemic event requiring medical attention
* estimated creatinine clearance less than 30 ml/min
B: Inclusion Criteria:

* age 50+
* English or Spanish speaking
* Prescribed 3+ medications
* Primarily responsible for administering own medication
* Owns a cell phone and feels comfortable receiving texts
* Access and proficient in using internet at home and has a personal email address

Exclusion Criteria:

* Major cognitive, visual, or hearing impairment
* Doesn't meet inclusion criteria.
C: Inclusion Criteria:

* patients age 55 and older
* admitted to the general medicine, family medicine, cardiology, and neurology services at San Francisco General Hospital,
* able to communicate in either English, Spanish, Mandarin or Cantonese,
* attending physicians agree to the patient's participation.
* Patients must be able to demonstrate an understanding of the study's goals through a set of teach back questions included in the consent process.

Exclusion Criteria:

* transferred from an outside hospital;
* admitted for a planned hospitalization (e.g. chemotherapy, a planned surgery)
* requiring hospice, nursing home, rehab or other institutional settings (i.e. expected by the physician team to be discharged to skilled nursing facilities) - those unable to independently consent (i.e. severely cognitively impaired, delirious, deaf, or involuntarily hospitalized because of severe mental illness)
* unable to understand English, Spanish or Cantonese (as reported by medical teams or unable to complete the consent teach-back process)
* less than age 55
* aphasic
* otherwise excluded by the medical team
* participated in the pilot project of this intervention.
D: Inclusion Criteria:

* Patients aged≥70 years with a long-term illness scheme or hospital admission the past 3 months
* Visiting their preferred general practioner (GP) or another GP in the same practice
* patient oral non opposition

Exclusion Criteria:

* Patient who does not speak French
* Severe disease with a life expectancy \<12 months
* Institutionalized patients
* Patient insured under the French national health insurance system

Answer: D