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:

* 70 years of age and over
* The patient lives independently or in a home for the aged
* The patient has a health problem that was recently presented to the GP by the patient or informal caregiver
* The request for help is related to the following problem fields: cognitive disorders, behavioral and psychological symptoms of dementia, mood disorders, mobility disorders and falling, or malnutrition
* The patient/informal caregiver and GP have determined a goal they want to achieve
* Fulfill one or more of these criteria: MMSE (Mini Mental State Examination) equal to or less than 26, GARS (Groningen Activity Restriction Scale) equal to or greater than 25 or MOS-20/subscale mental health equal to or less than 75

Exclusion Criteria:

* The problem or request for help has an acute nature, urging for action (medical or otherwise) within less than one week
* The problem or request for help is merely a medical diagnostic issue, urging for action only physicians (GP or specialist) can offer
* MMSE \< 20 or proved moderate to severe dementia (Clinical Dementia Rating scale \[CDR\] \> 1, 0) and no informal caregiver (no informal caregiver is defined as: no informal caregiver who meets the patient for at least once a week on average)
* The patient receives other forms of intermediate care or health care from a social worker or community-based geriatrician
* The patient is already on the waiting list for a nursing home because of the problem the patient is presented with in our study
* Predicted prognosis \< 6 months because of terminal illness
C: Inclusion Criteria:

* Frail community dwelling elderly patients aged 70 years or above. Frailty is determined with a two-phase screening instrument.

Exclusion Criteria:

* Non-frail elders
* Patients in palliative or end-of-life stages of disease
* Patients residing in long-term care facilities (care homes and nursing homes)
* Patients already enrolled in specific dementia-related case-management programmes who lack other health-related problems
* Patients not speaking or understanding the Dutch language
D: 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

Answer: A