Please select the eligibility criteria that correspond to the clinical trial below.
Title: Efficacy of Integrated Care to Decrease Hospitalization and Institutionalization in Community Dwelling Frail Elderly, With Care Coordination Between Physicians, Home Nursing Services and a Community Geriatrics Unit.
Brief Summary: Introduction: Care of frail and dependent elders with multiple chronic conditions is a major challenge for health care systems. The objective of this study is to evaluate the effect of coordinating the existing structures in the private and public sector for the care of frail and dependent persons over age 60, and susceptible of presenting complex bio-psycho-social issues. This approach is aimed at improving the coordination, continuity, quality and efficacy of care in this population, which presents a high risk of hospitalization, emergency room visits, institutionalization and mortality.

Methods: Three-year cluster randomised controlled trial. A control group receiving usual care (follow up by primary care physician and home nursing service) will be compared to an intervention group that will be provided, in addition, in-home multidimensional geriatric assessment with access to a 24h/7 day a week call service, and coordinated long-term follow-up. Survival analyses will be conducted to compare the outcomes between groups.

Primary outcome:

- Hospitalizations: rates of first hospitalization, number, cause and length of stay.

Secondary outcomes:

* Emergency room visits: rates of first visit, number and cause
* Institutionalization: number of patients
* Mortality: rate and number of deaths and place of death (home versus hospital)


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:

The inclusion criteria for this trial were the "frail elderly" defined as:

* community-dwelling persons aged \> 75 years,
* having more than three chronic diagnoses,
* prescribed six or more pharmaceutical drugs for continuous use and
* with at least three hospital stays (\> 24 hours in hospital) during the last six months.

Since these criteria were broad in order to capture relevant individuals, but also likely to generate persons of no relevance to the MGT intervention, identification of the study sample was conducted in three steps, in turn, repeated in three waves.

Exclusion Criteria:

* Persons not able to take part in qualitative interviews
D: Inclusion Criteria:

* Any community-dwelling patient of McMaster Family Health Team over the age of 70

Exclusion Criteria:

* Patient is palliative or receiving end-of-life care
* Patient is deceased
* Has explicitly stated that they do not want to be part of a research project
* Patient resides in long-term care
* Patient has indicated that they do not want to receive a home visit from trained community volunteers.
* Patient or family member does not speak English
* Patient will be out of the country for more than 50% of trial duration

Answer: A