Clinical Trial on the Effectiveness of the Model of Centered Care in the Person in the Geriatric Population at Home(Project AICP.Com)

It is an individualized care model and therefore difficult to define in a concrete way: it is based on respect for the individual characteristics of each person (their beliefs, values, preferences, life history, projects, goals...) to find the available family, social and community resources that best suit them in order to promote their autonomy, their quality of life and their emotional well-being.

The design of the randomized clinical trial proposed here is an external collaboration, not financed, which is adapted to the aforementioned project in its community setting and does not affect it beyond the qualification of the definition of the clinical variables of interest without modifying its original design. With it, it seeks to increase the emerging body of published scientific evidence in favor of carrying out this type of community and primary health care interventions that are centered on the person.

The project consists of a set of complementary actions that are considered convenient for the implementation and validation of the Comprehensive and Person-Centered Care Model (MAICP) and is aimed at elderly people in a situation of dependency or loneliness in two areas of action: homes and homes in their community settings.

The MAICP is articulated on two axes: placing the person at the center while the other elements revolve around them, and organizing support and care in a coordinated manner so that they are offered to the person in their community environment in an integrated manner and that This is not the one that must adapt to the uncoordinated and fragmented existing services. Specifically in the community environment (population at home), the objective is the articulation and coordination of both formal public services, as well as existing community and proximity resources in each environment to encourage older people to continue living at home and in their community in decent conditions, avoiding institutionalization and without burdening families. Work will be done in close collaboration with community social services so that they appropriate the elements and techniques proposed by the model at the end of the project. In it, methodologies such as community intervention, case management, life history and care plans and support for the life project will be articulated, through a professional relationship that promotes good care and maintenance of the dignity of people and their rights, as well as their autonomy to maintain control of their lives. The synergies and use of existing resources in each environment will affect the effectiveness of the MAICP.

Eligibility Criteria:
Inclusion Criteria:

1. Situation of Fragility (defined as social vulnerability by Social Services, based on a global qualitative assessment: loneliness, low level of education or resources, home conditions...) or recognized dependency, who live alone and who do not meet criteria for the third group.
2. Recognized dependency (classified as grade I, II or III according to the Dependency Law based on autonomy for basic activities measured by the Barthel scale and cognitive impairment according to Pfeiffer) who have cohabitants and who do not meet the criteria for the third group.
3. Dependence recognized grade II or III that also meet criteria of clinical complexity, at least 2 major criteria and 1 minor:

Major Criteria: polypharmacy \>4 active prescription drugs, \>=2 visits to the emergency room last year, \>=1 hospital admission in the last year Minor criteria: diagnosis of heart failure, COPD, dementia, and/or Liver disease / diabetes mellitus / osteoarthritis (2 of these 3).

Exclusion Criteria:

* those people who during the baseline period (summer 2022) present an event at the end of follow-up (see Variables) will be excluded.

Relatives or partners of other participants who have already been recruited for meeting inclusion criteria will also be excluded, with the most dependent person being the one with priority for inclusion in the study.