Efficacy of Integrated Care to Reduce Hospitalization and Nursing Home Placement in Community Dwelling Frail Elderly

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)