Membership of working party

Dr Jackie Morris
Dr John Gladman
Dr Ian Donald
Dr Willie Primrose
Dr Finbarr Martin
Dr Clive Bowman
Dr Gordon Campbell
Dr Chris Turnbull
Dr Chris Foote
Dr Tony Luxton
Dr Eileen Burns
Dr Elizabeth Raw
Dr Amanda Thompsell
Mr Richard Lynham

Recommendations to the Society and summary for the compendium

The long term conditions agenda is one that is central to our speciality. There is no other speciality that is better served to take the professional lead in this process. Engaging in this process constructively will help the Society strengthen the speciality, not least because it focuses on aspects of geriatricians’ work other than acute internal medicine. More importantly, if case management is a success, then much of what we now understand as geriatric medicine will be done in this process. Geriatricians cannot afford to be left out of it, or even to be side-lined. For this reason we advise the Society to take a major role at all levels to work constructively on the case management agenda. This includes:

• Promoting community geriatricians in support of this process
• Reviewing training of geriatricians for this role
• Examining the CPD for geriatricians in this role
• Taking a lead on the multi-disciplinary education and training of staff involved in these services
• Identifying the R&D needs in this process.

Summary
The Department of Health’s focus on case management provides the speciality of Geriatric Medicine with an opportunity to review and strengthen its partnership with primary care. The basis of the practice of the speciality is the multi-disciplinary approach i.e. “Comprehensive geriatric assessment” which has been shown to be effective in improving the quality of life in frail, vulnerable older people with complex medical conditions.

The three level pyramid is useful to clarify the conceptual issues but the implementation of case management requires a more detailed model. Although we welcome the introduction of local solutions using community matrons there will need to be established common processes to ensure an equitable delivery of service. Evidence suggests that case management of a population is successful in reducing mortality and institutionalisation rates.

A more integrated model of care encompassing health and social care systems should replace the traditional primary, secondary and intermediate care, see figure 1 below:

Figure 1

Fundamental to any system managing long term conditions is the right of the patient to access appropriate types of treatment, as shown in the model, delivered in a flexible and collaborative fashion wherever the patient lives. These should include:

• Acute treatment
• Comprehensive assessment and review
• Rehabilitation and re-enablement
• Palliative care and end of life care

A considerable number of frail complex older people suffering from long term conditions live in care homes and in some areas account for a disproportionate number of admissions to acute hospitals. The care management system has been demonstrated to be effective in the United States and could be used in the United Kingdom.

The role of the geriatrician should include:

• Management of older people with several long-term conditions as well as common conditions in older people affecting their function for example Parkinsonism.
• Providing advice at times of transition, recognising the limitations of active intervention and the importance of palliation.
• Providing professional support for assessment processes used on older people and regular reports to Primary care trusts and hospital boards regarding performance. Such reporting should inform on rates of institutionalisation, hospitalisation, and access difficulties for community care.
• Leadership of clinical governance arrangements for services outside the hospital.
• Nurturing the multidisciplinary team in the primary care sector
• Teaching and research
• Leading and facilitating the evaluation of services for long term conditions

Introduction

The British Geriatrics Society welcomes the Department of Health’s recent emphasis on long-term care, particularly its interest in case management for the most vulnerable individuals [1]. The speciality of geriatric medicine began in the first half of the twentieth century with the intention of improving the quality of life of vulnerable elderly people, and over the intervening years has provided compelling evidence that the multi-disciplinary approach, known as “comprehensive geriatric assessment” is effective in improving quality of life of frail, vulnerable older people [2, 5, 6, 7, 8, 9]. The skills, knowledge, practice and experience needed for comprehensive geriatric assessment and effective case management have much in common.

The advent of case management provides the speciality of geriatric medicine with an opportunity to renew and strengthen its partnerships with primary care. The British Geriatrics Society recognises the central impor tan ce of primary care, noting that it has a population base, the first pre-requisite for delivering managed care, and a commitment to continuity of care. Primary care has also encouraged the development of nurse-led clinics in areas such as asthma, diabetes, and vascular disease, thereby helping to develop a highly trained and experienced multi-disciplinary workforce.

The Department of Health has used a 3-level pyramid to distinguish between various elements of the management of long term conditions (supported self care, disease specific care management, and case management). This classification is useful to clarify conceptual issues, but to implement case management requires a more detailed model of services. This report draws upon the skills and knowledge of community geriatricians to outline such a model.

Current models and understanding

The DoH policy towards the management of long term conditions [1] is to focus on case management. Its advice and that of the recent joint report from The Royal Colleges of Physicians and General Practitioners [3] is to develop local solutions following local needs assessment, using community matrons as case managers. Whilst every health service must be implemented according to local need and therefore will necessarily differ to some extent from other services around the country, there will be a commonality at the theoretical level in terms of the relationships between the structures and process of the service and the experienced outcomes of the patients.

Recent UK experimentation in case management has borrowed from experience from the health care architecture in the USA, which differs greatly in terms of the practice of Primary Care, the extent of geriatric medicine, and the financial incentives that drive activity. The Kings Fund [4] has questioned the applicability of research findings in the US nursing home to the community setting in the UK . Their review of the evidence around case management has shown that case management of a population, rather than a high risk subgroup, is successful (Bernabei [5] and Hendriksen [6]), and that subjects with low-level disability, and not high disability, benefit from proactive care [7-8]. Meta-analyses have shown that these benefits are chiefly in reduced mortality and institutionalisation rates, rather than reduced hospital admissions [9]. Targeting older patients with several admissions may be too late, as this group has a high mortality, and account for a relatively small proportion of admissions the following year [10]. The population at highest risk is constantly changing.

The 3-level pyramid model of the management of long term conditions should not be used to imply that elements of level 1 (supported self care) and level 2 (disease specific care management) do not take place in level 3, case management. There may also be an erroneous understanding that, because of the importance of reducing the rate of hospital admission, acute and hospital care is not part of case management. In practice a more complex model is needed to account for the complexities of the nature of services for vulnerable people.

We suggest a model derived from a whole systems understanding of health services for vulnerable people that is free of assumptions about the health architecture in which it is implemented, and which is sufficient to account for its complexity.

Core processes for Health Care of Older people – a new model

Figure 2 is a schematic diagram of the core processes for high quality health care for older people.

At the top of the diagram are three boxes representing three types of care that a single individual may need. One or more chronic diseases become almost inevitable with increasing age. Frailty refers to a state when there are multiple conditions, particularly in advanced old age where physiological reserves are limited and where social and economic adversity is common. Although people do not commonly move from being frail to being not frail, this may happen and hence all the arrows in the diagram are doubled headed: a person may move in and out of acute care, and in and out of frailty. Many frail people live in the care home sector, but many choose and are able to live in their own homes. Acute care will be needed for the management of changes in health, and may be delivered at home by their GP, within intermediate care, or in hospital. It is a common requirement within the management of long-term conditions, because many of these diseases fluctuate in severity, and are prone to destabilisation. This model recognises the nitration between level 2 and level 3 chronic disease management.

Management of frailty

Frailty management may be the least well developed of these three processes in the UK , yet it consumes a huge amount of health care. The management of frailty has been acknowledged as the cornerstone of the geriatrician’s work [11]. Yet emphasis on providing acute care has led to a relative lack of interest in, and disengagement from, the frail individual. The particular needs within this process of care include someone to contact and trust, a sensitive truly patient-centred approach to decision-making, often a simplification of treatments and medication, and discussion of end-of-life issues.

Importantly, the diagram shows, in the uppermost tier of blue arrows, four processes essential for the coordinated delivery of a high quality service that meets the needs of the frail, those with simpler chronic conditions and their requirement for acute care.

Assessment

Assessment is a core process. The rationale for the Single Assessment Process recognises the central rationale of assessment. Assessment is a process rather than a single event. In case managed services, the case manager will usually be central to assessment, but the GP will usually be involved when acute care is considered. Out of hours services and Emergency Departments are also involved in the assessment process when acute care is considered. The geriatrician is particularly valuable in the assessment process where the deterioration in health is non-specific, making the underlying diagnoses obscure. A typical example is deterioration in mobility, which may be due to the interaction of the effects of medication, cognitive and physical ability: this often requires an understanding of the pathophysiology of syncope, pre-syncope and dizziness that non-experts do not have.

Rehabilitation and re-enablement

Rehabilitation and re-enablement are also essential. Activity limitation and participation restriction are frequently associated with the impairments associated with long term conditions and the environmental and social adversity that often accompanies them. Interventions to improve health (promote activity and participation) may be at the social or environmental level, or problem solving to promote the performance of activities, and hence are typically inter-disciplinary and inter-agency. Recognising the need for such interventions is one of the assessment skills of the case manager. The rehabilitation process frequently requires input from the medical profession, typically to identify and treat the medical barriers to rehabilitation ( such as i nfection, thromobembolic disease, co-existent cardiores p iratory disease, p ain, depression). This will be done by the GP for most people being case managed. However, the geriatrician is likely to be needed where team membership is required for the intervention to be effective (such as in i Intermediate c Care) or where the barriers are not immediately evident.

Population management

Population management requires a whole system perspective to planning. This process requires needs assessment to ensure that the size the service is sufficient. In resource limited systems, as are all health care system, the effect of a new service upon the working of other elements of the entire service must be considered. Equity and justice need to be considered to ensure balance and to ensure that the greatest good is served. The community geriatrician, whose work typically spans both primary and secondary care, is in an ideal position to give advice on these matters.

End of life care

The case management of long term conditions does not always imply long term care. On the contrary, one of the most defining features of frailty is its closeness to the end of life, a time that for many people is marked by multiple admissions to hospital, and considerable health care expenditure. Some of this activity may be undesirable or futile from the patient’s perspective, and may obstruct the delivery of good palliative and terminal care. End of life care and its planning is therefore an unavoidable element of case management. The geriatrician can play a valuable role in this process, by providing information based upon a first hand knowledge of what can and cannot be achieved in hospital and from frequent practical experience of the management of complex final illnesses.

These four processes do not operate in a vacuum, and are underpinned by deeper foundations, again which will benefit from the input of a geriatrician.

Team working

The above four processes are crucially dependent upon teamwork. For example, for rehabilitation to be successful it is common that several interventions need to be made, by several different individuals, before the conditions are met for successful performance of an activity.

A danger of developing new services is that they may increase fragmentation of the overall service. Every aspect of the operational policy of a service must be examined in the light of whether it encourages team working. Of central importance here is the need for accurate, relevant, shared information.

Teaching and research

The case management approach to the management of long term conditions poses extreme workforce challenges, in particular by ensuring that the case managers have sufficient skills to handle the grave responsibility that they will handle. Without such skills, patients will be at risk and GPs will not have the confidence to delegate responsibility to them. Geriatricians can contribute towards the training of case managers.

As in any health care development many information needs are identified. Frequently the evidence base that services require lags behind their implementation (“Ready, Fire, Aim”). Research activity must be closely associated with service development. Departments of geriatric medicine can contribute to such research and should be actively involved in the process at an early stage. Research should be integral to service development, not an optional extra or simply lip-service.

Evidence and evaluation

Good governance requires services to be audited and quality assured. This requires members of the service to undertake continuing professional development, for services to have mechanisms to adapt to new knowledge, and for quality assurance to be integral. Geriatricians can contribute to this process. The British Geriatrics Society in particular has a brief to support the continuing education of geriatricians, and provide them with the means to evaluate clinical and professional practice. Although the British Geriatrics Society is principally an organisation for doctors, it recognises its multi-disciplinary responsibilities, and provides a natural host organisation for professional development and evaluation in this field.

Societal values

The experience an old person actually has is heavily dependent upon the attitudes of those who they have day to day contact with. The attitudes and behaviour displayed by staff in the front line is in part dependent upon the attitudes of the society in which they operate. The influences upon society’s attitudes are multiple, but are often brought to bear through explicit policies, the consequences of which are often not anticipated by those making them. For example, we note that the main intention of case management is to optimise the lives of frail and people with multiple disease and yet the principal service target is to reduce hospital admission rates: we accept that very often these two will not be in conflict, but argue that such ambiguity could lead to occasions where hospital admission is denied at the expense of the optimal health of an older person. The British Geriatrics Society can act as an adviser towards policy makers, and is centred around patient welfare: its mission being since its birth in 1947 “the relief of suffering and distress amongst the aged and infirm…”.

Figure 2 Relationship of Core Processes for health care of older people

Managing Long-term conditions in Care Homes

The population management approach referred to in the above model reminds us that in most Primary Care Trusts, or similar units of health care responsibility, a considerable proportion of the people with long term conditions are in care homes. In some areas, residents of care homes account for large disproportionate numbers of hospital admissions. The British Geriatrics Society sees no reason why residents of care homes should not benefit from high quality case management services, and notes that the models of case management from the USA that have recently been tried in the UK are mainly based in nursing homes. It is recognised that the management of long-term conditions in care homes separately and care is subject to a different set of standards and regulations.

Nevertheless, the advent of case management services, being community based, provides the opportunity to improve the quality of care and life for people living in the care home sector. In many parts of the country the usual models of primary care provision do not make it easy to deliver high quality care to residents of care homes, particularly in areas where there is a high density of homes or when many practices have responsibility for different residents of the same home.

In essence the model of care needed for people in care homes is no different from that needed for people with long term conditions in other settings: end of life care and planning is a particular priority in nursing homes.

An example of an innovative development in Chester le Street Newcastle is outlined below and illustrates that active organisation of services in primary care can create the service structure that is capable of delivering the core processes of high quality care to care home residents. This is not an approach that can necessarily be replicated elsewhere, but it is an illustration of what can be achieved with innovative thought.

Care Homes in Newcastle
Castlegarth Practice,
Durham and Chester le Street Primary Care Trust
This practice was established to provide proactive care solely to the frail elderly residents of residential and nursing homes in Durham and Chester le Street.

The practice is currently staffed by 2 full time nurse practitioners who it is envisaged will case manage 100 patients each in several different nursing homes. Medical support to the nurse practitioners is provided by GPs. The practice will should increase in size over time, registering new patients admitted to long term care and the staff will grow to support this. Geriatric medical input is provided by a GPwSI in geriatrics for 4 sessions per week.

The practice plans to target key areas specifically relevant to this patient group. For example in geriatrics and as such this year, a local Quality and Outcome framework for the new GP contract , is being developed incorporating falls assessment. Target areas for the future include: palliative care, tissue viability and continence. The style of practice is proactive, rather than reactive care : this is likely to be both efficient as well as effective. The practice liaises monthly with the secondary care geriatric medical department, as well as forging links with occupational therapy OT, physiotherapy, dieteticicians, the continence team, and tissue viability services. Practice staff work closely with the staff in the care homes and an ongoing educational programme is in development that will specifically support the clinical target areas.

An example of the service in practice includes an elderly lady in a residential home with cognitive impairment who, over a few weeksbecame more agitated and had sustained several falls resulting in numerous trips to the Emergency Department A and E in the preceding weeks. Home review with comprehensive geriatric assessment by assessment by the team revealed two unrecognised diagnoses: a large postural hypotension (a treatable condition that commonly causes falls and blackouts) drop in her blood pressure and thyrotoxicosis (another easily treated condition, due to an over active thyroid gland which caused many of her symptoms). After treatment she was less agitated had no further falls.

Health Care systems around the UK

The traditional division of health care into Primary and Secondary and more recently Intermediate Care is not well suited to the needs of people with long-term conditions. Such people require a more integrated care model, based upon networks across the health and social care systems. Indeed this has been acknowledged, with proposals of Care Trusts, and clinical directorates spanning hospital and community care. It is a challenge to ensure that Foundation Trusts and Payment By Results do not increase the fragmentation of services in England and Wales.

• An alternative structure has been developed in Scotland , which can promote integrated care, namely:
  
  The Scottish Executive is introducing Community Health Partnerships (CHP’s) from 1 st April 2005 to deliver locality focussed integrated health and social care. These are replacing local Healthcare Cooperatives (of GP’s), Primary Care Operating Divisions (formerly Primary Care Trusts) and previous Joint Future Partnerships between health systems and local authorities. Acute Operating Divisions (formerly Acute Hospital Trusts) are also expected to participate in the process.
• The CHP’s are charged to manage and provide, or have a lead rol e in coordinating, a range of services including childrens, mental health, learning disability, primary medical services, chronic disease management, community based integrated teams (e.g. rapid response), joint health and social services for older people, community assessment and rehabilitation and palliative care in community hospitals. They will be accountable to unitary NHS Boards (Health Authorities). Geriatricians have been urged to engage with CHP’s in order to improve local services and influence allocation of shared resources .

Flexibility yet consistent standards

The differing patterns of long-term conditions, their different settings (in care homes or private residences; urban and rural), the different ethnic mix of population, and differences in organisation of Primary Care across the UK mean that service structures cannot be the same.

The lack of an identical service structure should not be used however as an excuse for poor standards of care. Our model illustrates the core processes that all services need to demonstrate, but we appreciate that knowledge of this alone does not assure that the standards of care will be high.

The Royal Colleges of Physicians and General Practitioners [3] identified key ingredients to successful implementation, which included:

• Clinical leadership
• Communication - trust and team working
• Close working across the Primary / Secondary care interface
• Patient involvement
• Shared records
• Use of clinical governance

These are the same ingredients which create successful networking, and success in our central processes of acute care, chronic disease management, and frailty management.

What the community geriatrician brings to case management

The British Geriatrics Society believes that geriatricians are necessary to the successful implementation of case management. A community geriatrician will typically work across community and hospital settings, providing expertise in the acute and chronic care that the recipients of case managed care require. A geriatrician will contribute usefully to the assessment process, by providing an adequate diagnosis, particularly in complex settings when illnesses are presenting non-specifically or when iatrogenic problems are suspected. The geriatrician’s understanding of prognosis in frail older people is useful in planning care at the end of life. The geriatrician can work with case managers and the teams that support them (such as i Intermediate c Care teams) to identify and treat the medical barriers to rehabilitation. Geriatricians can complement teams, help train staff and maintain their on-going development, help in assuring standards and help in developing the research and development agenda.

From our experience we advise that there should be at least one identified geriatrician linked to each locality (in England and Wales , a Primary Care Trust) to support the local network of case management. Such arrangements are now in place in many parts of the UK – one example is Leeds :

Leeds has a history of very high hospital usage and the hope was that intermediate care might allow a cohort of patients to avoid hospital admission. However, early indicators showed a lack of impact on hospital activity. An experimental secondment by one geriatrician facilitated as well as prevented hospital admissions, with many patients requiring specialist medical support. The intermediate care team welcomed the geriatrician’s role, enabling them to manage patients who would otherwise have been admitted. The local GPs were also very positive about the role, indicating also a willing to support patients in the community with the additional input of the community consultant.

Each of the 5 PCTs in Leeds agreed to fund 0.5 WTE consultant geriatrician to work part-time in the acute trust and part time in the community. The role of the community geriatrician is to support all aspects of intermediate care. With the advent of chronic disease management nurses they also are developing a close working relationship to support these staff. Future targets are comprehensive geriatric assessment of all older people considering a move into long term care is another area to address, and meeting the health needs of residents of nursing homes more effectively.

The role of the geriatrician should include:

• Providing investigation, diagnosis and management for older people with several long-term conditions.
• Providing advice at times of transition, recognising the limitations of active intervention and the importance of palliation.
• Providing specialist advice for conditions that are common in older people but not everyday conditions for general practitioners, e.g. Parkinsonism
• Providing professional support for assessment processes used on older people and regular reports to PCT and hospital boards regarding performance. Such reporting should inform on rates of institutionalisation, hospitalisation, and access difficulties for community care.
• Leadership to clinical governance arrangements for services outside the hospital, with support from primary care physicians and social services.
• Nurturing the multidisciplinary team, contributing to service development and training.

Further examples of how geriatricians are participating in Case management projects are outlined below:

Evercare in Bristol – working with consultants
The project aims to prevent inappropriate emergency admissions of patients over the age of 75 years and, if admitted, to facilitate early discharge by proactive, multidisciplinary case management and the development of robust systems for recording and sharing relevant information across organisations and agencies. The project identifies patients aged 75 and over who are vulnerable to admission through clinical opinion (‘gut feeling’) within the multidisciplinary team. A multidisciplinary team meets each month to review the vulnerable patients. Key workers (health or social care professionals) are identified who work in partnership with the patient and family, and explore the needs of all concerned. Ideally the t Team consists of g General p Practitioners, d District n Nurses, p Practice n Nurses, n Nurse p Practitioners, o Occupational t Therapists, p Physiotherapists, s Social w Workers, c Community p Psychiatric n Nurses and c Care m Managers. The role of a g Geriatrician, local c Community p Paramedic, c Community P p harmacist and the local a Assistive t Technology l Lead is being evaluated at present.

The key worker helps to identify emerging problems at an early stage. They provide holistic assessments of that patient and request further specialist assessment if required. They also help to provide the link between primary and secondary care, thus helping to provide a seamless service for the patient being discharged from hospital and providing additional information to help this happen. The project uses patient-held summary records, kept alongside nursing notes, which should accompany the patient into hospital.

The project aims to prevent inappropriate emergency admissions of patients over the age of 75y and, if admitted, to facilitate early discharge by proactive, multidisciplinary case management and the development of robust systems for recording and sharing relevant information across organisations and agencies.

The project identifies patients aged 75 and over who are vulnerable to admission through clinical opinion (‘gut feeling’) within the multidisciplinary team. A multidisciplinary team meets each month to review the vulnerable patients. Key workers (health or social care professionals) are identified who work in partnership with the patient and family, and explore the needs of all concerned. Ideally the Team consists of General Practitioners, District Nurses, Practice Nurses, Nurse Practitioners, Occupational Therapists, Physiotherapists, Social Workers, Community Psychiatric Nurses and Care Managers. The role of a Geriatrician, local Community Paramedic, Community Pharmacist and the local Assistive Technology Lead is being evaluated at present.

The key worker helps to identify emerging problems at an early stage. They provide holistic assessments of that patient and request further specialist assessment if required. They also help to provide the link between primary and secondary care, thus helping to provide a seamless service for the patient being discharged from hospital and providing additional information to help this happen. The project uses patient-held summary records, kept alongside nursing notes, which should accompany the patient into hospital.

The Cambridge experience of working in a locality

Cambridge has one PCT-based community geriatrician and several hospital-based consultants with varying types of community responsibility ranging from traditional community hospital rehabilitation and continuing care wards and clinics ( f Falls, Parkinson's disease and general) to active involvement with community-based developments. Examples are:

• Two practices piloting a vulnerable people register with the aim of intervening early and avoiding crises and providing folders of information to accompany them to hospital, further practices will become involved. The geriatrician advises on how best to manage or investigate problem cases, by discussion at meetings, seeing them at home or in outpatients.
• Visits to nursing homes with the general practitioner to advise on the most frail and vulnerable for whom outpatient attendance would be impractical and hospital admission undesirable.
• Assisting with acute hospital "front door" community teams to identify those who can return to their usual residence with increased support, or to a community hospital or care home bed for rehabilitation and recovery.
• Support ing some direct admissions to community-based facilities.

Next steps

The British Geriatrics Society will demonstrate its commitment to making the DoH policy for supporting long-term conditions as success by the following steps:

• Strengthening the training of geriatricians for this role, through a review of current training schemes and the provision of special training
• Promote the community geriatrician role within the speciality
• Develop continuing education programmes for geriatricians with this interest
• Liaise with other professional groups to co-ordinate the training of case managers
• Liaise with other groups to identify the R&D issues and to promote R&D in this area

The British Geriatrics Society encourages each Primary Care Trust, as they plan the implementation of the DoH policy for supporting long-term conditions in older people, to :-

• Identify a geriatrician for each locality, and involve them in a review of the local needs
• Review the adequacy of acute care, chronic disease management for the most common conditions in their locality, and frailty management for older people, and identify components currently weak or missing.
• Review progress in the implementation of the Single Assessment Process
• Consider the most appropriate model for introducing care management or care coordination to improve networking and communication.

References

1. Supporting people with long-term conditions: an NHS and Social Care Model to support local innovation and integration. Department of Health Jan 2005.
2. Stuck AE, Siu AL, Wieland GD et al Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet 1993;342:1032-6
3. Clinicians, services and commissioning in chronic disease management in the NHS: The need for coordinated management programmes. Royal College of Physicians 2004.
4. Case-managing long-term conditions: what impact does it have in the treatment of older people. King’s Fund July 2004.
5. Bernabei R, Landi F, Gambassi G et al Randomised trial of impact of model of integrated care and case management for older people living in the community. BMJ 1998;316:1348-1351
6. Hendriksen C, Lund E, Stromgard E. Consequences of assessment and intervention among elderly people: a 3 year randomised controlled trial. BMJ 1984;289:1522-1524.
7. Stuck AE, Minder CE, Pter-Wuest I et al A randomised trial of in-home visits for disability prevention in community-dwelling older people at low and high risk for nursing home admission. Arch Intern Med 2000;160:977-986.
8. Gill TM, Baker DI, Gottschalk M et al A program to prevent functional decline in physically frail, elderly persons who live at home. NEJM 2002;347:1068-1074.
9. Elkan R, Kendrick D, Dewey M et al Effectiveness of home based support for older people: systematic review and meta-analysis. BMJ 2001;323:719-723.
10. Donald IP Is Evercare too late? Age and Ageing accepted for publication
11. Rockwood R, Hubbard R Frailty and the geriatrician Age and Ageing 2004;33:429-430.