Preventive Primary Care Outreach for High Risk Older Persons

It is recognized that a significant proportion of seniors over 75 years of age are at risk of functional decline, and thus of institutionalization and death. The investigators at McMaster University Medical Centre, are conducting is a randomized controlled trial of a preventive primary care outreach (PPCO) service provided to high risk seniors living in the community. The goal of this service is to identify unrecognized problems and individuals at increased risk and to link individuals to care. This preventive primary care service is provided by nurse case managers. The investigators have recruited patients through their family physicians who work in primary care networks. The investigators are screening all seniors aged 75 and over within these practices. The sample includes seniors aged 75 and over who are identified to be at risk according to the Sherbrooke Postal Questionnaire. Patients are randomly allocated to intervention and control groups. A research assistant, who is blind to group allocation, will collect data from seniors at baseline, six months, and at the end of one year. Outcome measures include health-related quality of life (quality adjusted life years \[QALYs\]), health and social service utilization and costs, mortality, institutionalization, functional status, and perceived health status. Primary Hypothesis: The intervention compared to usual care will result in higher health-related quality of life. Secondary Hypotheses: Compared to usual care, the PPCO intervention will result in: * the same or lower costs associated with service utilization; * less functional decline; * reduced mortality; * lower rates of institutionalization; and * better self-rated health.