Search

Background: During the first wave of the COVID-19 pandemic, it is estimated that around 25% of infected residents in Nursing Homes in Catalonia died, which accounted for more than 50% of total COVID-19 deaths in the region. This devasting impact not only highlights the structural deficits of the long-term care facilities system, but it also provides a unique opportunity to gather evidence to support a redesign of the health and social care models–a redesign that focuses on individuals and their singularities, and is equipped with the staff and infrastructure required to meet their needs. Methods: The ResiCOVID-19 project will include five work packages to assess the impact of the COVID-19 pandemic (from March 2020 to June 2022) on the individuals living in long-term care facilities in Catalonia, their family members, health care workers, and the organisations themselves. In this project, we will develop proposals for improvement and indicators for the long-term care model in Catalonia to better adapt to the current and future needs of people-centred care through conducting a rapid review, analysis of international experiences, retrospective analysis, and a cross-sectional study. The analysis will be conducted both from a quantitative and a qualitative perspective, measuring the impact at a system level as well as at a setting and individual level, including residents, families, professionals, and managers of long-term care facilities. Conclusions: The ResiCOVID-19 project is expected to have a significant impact at different dimensions, including the care model, social and organisational aspects (on professionals and facilities), systemic efforts (both for the healthcare and the social systems), and scientific contributions (providing evidence in a field of limited research in Catalonia).

Introduction: This study aimed to assess the implementation of integrated social and health home care services (HCS) offered by the Government of Catalonia, and to identify the main barriers and facilitators of integrated HCS. Methods: Analysis of the degree of implementation of integrated social and health HCS perceived by social care services (SCS) and primary health care centers (PHCs) between December 2020 and June 2021 in two phases. First, the perception of integration by social workers within SCS and PHCs was assessed using a screening questionnaire. Then, SCS in counties with the highest integration scores received a customized questionnaire for an in-depth assessment. Results: A total of 105 (100%) SCS and 94 (25%) PHCs answered the screening questionnaire, and 48 (45.7%) SCS received a customized questionnaire. The most frequent barrier identified was the lack of shared protocols, with the most frequent facilitator being the recognition of the importance of integrated HCS. Conclusions: Our study showed that the degree of implementation of integrated health and social HCS offered by the Government of Catalonia was perceived as low. The identified barriers and facilitators can be used to facilitate such implementation. Further studies should include professionals other than social workers in PHC assessments.

Nursing home (NH) residents commonly face limitations in basic activities of daily living (BADLs), following a hierarchical decline. Understanding this hierarchy is crucial for personalized care. This study explores factors associated with early, middle, and late loss in BADLs among NH residents. A multicenter cross-sectional study was conducted in 30 NHs in Catalonia, Spain. Dependent variables were related to limitations in BADLs: early loss (self-care-related BADLs: personal hygiene, dressing, or bathing), middle loss (mobility-related BADLs: walking or wheelchair handling, toileting, and transferring), and late loss (eating). Independent variables were based on a comprehensive geriatric assessment and institutional factors. Logistic regression was used for the multivariate analyses. The study included 671 older adults. Early loss in BADLs was significantly associated with urinary incontinence, cognitive impairment, and falls. Middle loss in BADLs was linked to fecal incontinence, urinary incontinence, ulcers, and cognitive impairment. Late loss in BADLs was associated with fecal incontinence, the NH not owning a kitchen, neurological disease, cognitive impairment, dysphagia, polypharmacy, and weight loss. These findings highlight the need to address geriatric syndromes, especially cognitive impairment and bladder/bowel incontinence. Monitoring these syndromes could effectively anticipate care dependency. The presence of kitchens in NHs may help to address limitations to eating, allowing for potential personalized meal adaptation.

ObjectivesTo assess excess mortality among older adults institutionalized in nursing homes within the successive waves of the COVID-19 pandemic in Catalonia (north-east Spain).DesignObservational, retrospective analysis of population-based central healthcare registries.Setting and participantsIndividuals aged >65 years admitted in any nursing home in Catalonia between January 1, 2015, and April 1, 2022.MethodsDeaths reported during the pre-pandemic period (2015–2019) were used to build a reference model for mortality trends (a Poisson model, due to the event counting nature of the variable “mortality”), adjusted by age, sex, and clinical complexity, defined according to the adjusted morbidity groups. Excess mortality was estimated by comparing the observed and model-based expected mortality during the pandemic period (2020–2022). Besides the crude excess mortality, we estimated the standardized mortality rate (SMR) as the ratio of weekly deaths’ number observed to the expected deaths’ number over the same period.ResultsThe analysis included 175,497 older adults institutionalized (mean 262 days, SD 132), yielding a total of 394,134 person-years: 288,948 person-years within the reference period (2015–2019) and 105,186 within the COVID-19 period (2020–2022). Excess number of deaths in this population was 5,403 in the first wave and 1,313, 111, −182, 498, and 329 in the successive waves. The first wave on March 2020 showed the highest SMR (2.50; 95% CI 2.45–2.56). The corresponding SMR for the 2nd to 6th waves were 1.31 (1.27–1.34), 1.03 (1.00–1.07), 0.93 (0.89–0.97), 1.13 (1.10–1.17), and 1.07 (1.04–1.09). The number of excess deaths following the first wave ranged from 1,313 (2nd wave) to −182 (4th wave). Excess mortality showed similar trends for men and women. Older adults and those with higher comorbidity burden account for higher number of deaths, albeit lower SMRs.ConclusionExcess mortality analysis suggest a higher death toll of the COVID-19 crisis in nursing homes than in other settings. Although crude mortality rates were far higher among older adults and those at higher health risk, younger individuals showed persistently higher SMR, indicating an important death toll of the COVID-19 in these groups of people.

Abstract Background The identification of patients with advanced chronic conditions and palliative care needs is essential since their care represents one of the main challenges for public health systems. The study aimed to determine the prevalence and characteristics of inpatients with palliative care needs in different services of a tertiary care hospital using the NECPAL CCOMS-ICO© tool. Methods A descriptive, cross-sectional cohort study was conducted in a tertiary hospital. The NECPAL tool identifies patients who require palliative care. Any patient with the Surprise Question with the answer “NO” and at least another question of the tool with a positive answer is considered a positive identification. Patients were classified as Non-NECPAL, NECPAL I-II, and NECPAL III, depending on the NECPAL tool criteria they met. The presence of physical symptoms, emotional distress, and social risk factors was assessed. Results Of the 602 inpatients, 236 (39.2%) were enrolled. Of them, 34 (14.4%) non-NECPAL, 202 (85.6%) NECPAL+ [105 (44.5%) NECPAL I-II, and 97 (41.1%) NECPAL III]. Physical symptom burden was high (pain intensity ≥ 1 in 68.3% of patients; tiredness ≥ 1 in 83.5%; somnolence ≥ 1 in 50.6%; dyspnea ≥ 1 in 37.9%; anorexia ≥ 1 in 59.5%). 64.1% had emotional distress, and 83.6% had social risk factors. The NECPAL-III group contained a higher percentage of cancer patients, higher demand for palliative care, and greater need for palliative care (p

Abstract Background Frailty is a dynamic condition that is clinically expected to change in older individuals during and around admission to an intermediate care (IC) facility. We aimed to characterize transitions between degrees of frailty before, during, and after admission to IC and assess the impact of these transitions on health outcomes. Methods Multicentre observational prospective study in IC facilities in Catalonia (North-east Spain). The analysis included all individuals aged ≥ 75 years (or younger with chronic complex or advanced diseases) admitted to an IC facility. The primary outcome was frailty, measured by the Frail-VIG index and categorized into four degrees: no frailty, and mild, moderate, and advanced frailty. The Frail-VIG index was measured at baseline (i.e., 30 days before IC admission) (Frail-VIG0), on IC admission (Frail-VIG1), at discharge (Frail-VIG2), and 30 days post-discharge (Frail-VIG3). Results The study included 483 patients with a mean (SD) age of 81.3 (10.2) years. At the time of admission, 27 (5.6%) had no frailty, and 116 (24%), 161 (33.3%), and 179 (37.1%) mild, moderate, and severe frailty, respectively. Most frailty transitions occurred within the 30 days following admission to IC, particularly among patients with moderate frailty on admission. Most patients maintained their frailty status after discharge. Overall, 135 (28%) patients died during IC stay. Frailty, measured either at baseline or admission, was significantly associated with mortality, although it showed a stronger contribution when measured on admission (HR 1.16; 95%CI 1.10–1.22; p

Abstract Background In 2018, the European Working Group on Sarcopenia in Older People (EWGSOP2) updated the original definition of sarcopenia, establishing new criteria to be used globally. Early diagnosis of sarcopenia in nursing home residents and the identification of contributing factors would target interventions to reduce the incidence of malnutrition, social isolation, functional decline, hospitalization and mortality. Aim Verify the prevalence and the degree of severity of sarcopenia according to the new EWSGOP2 criteria and to analyse its associated factors in residents living in nursing homes in Central Catalonia (Spain). Design A cross-sectional multicenter study was conducted in 4 nursing homes. SARC-F test was applied as the initial screening, muscle strength was measured by a dynamometer, skeletal muscle mass by bioimpedance analysis and physical performance by Gait Speed. Four categories were used: total probable sarcopenia, probable sarcopenia, confirmed sarcopenia and severe sarcopenia. Results Among the total sample of 104 nursing home residents (mean age 84.6, ± 7.8; median 86, IQR 110), 84.6% were women and 85 (81.7%) (95% confidence interval [CI] 73.0-88.0) had total probable sarcopenia, 63 (60.5%) had probable sarcopenia, 19 (18.3%) had confirmed sarcopenia and 7 (6.7%) had severe sarcopenia. In the bivariate analysis, obesity was negatively associated and total time in sedentary behavior positively associated with all sarcopenia categories. In addition, malnutrition and urinary continence were positively associated with total and probable sarcopenia. Urinary incontinence was a positive associated factor of total and probable sarcopenia. In the multivariate analysis, obesity represented a negative associated factor: OR = 0.13 (0.03 - 0.57), p = 0.007 and OR = 0.14 (0.03 - 0.60), p = 0.008 with total and probable sarcopenia, respectively, adjusted by urinary incontinence status. For confirmed sarcopenia, obesity also represented a negative associated factor OR = 0.06 (0.01 - 0.99), p = 0.049 and the total time in sedentary behavior a positive associated factor OR = 1.10 (1.00- 1.20), p = 0.040. Conclusions According the EWGSOP2 criteria, high prevalence of sarcopenia was found in institutionalized older people, ranging from 6.7 to 81.7% depending on the category. Malnutrition, urinary incontinence and total time in sedentary behavior were associated with sarcopenia, whilst obesity represented a protective factor in this population.

Abstract Background The Frail-VIG frailty index has been developed recently. It is an instrument with a multidimensional approach and a pragmatic purpose that allows rapid and efficient assessment of the degree of frailty in the context of clinical practice. Our aim was to investigate the convergent and discriminative validity of the Frail-VIG frailty index with regard to EQ-5D-3L value. Methods We carried out a cross-sectional study in two Primary Health Care (PHC) centres of the Catalan Institute of Health (Institut Català de la Salut), Barcelona (Spain) from February 2017 to January 2019. Participants in the study were all people included under a home care programme during the study period. No exclusion criteria were applied. We used the EQ-5D-3L to measure Health-Related Quality of Life (HRQoL) and the Frail-VIG index to measure frailty. Trained PHC nurses administered both instruments during face-to-face assessments in a participant’s home during usual care. The relationships between both instruments were examined using Pearson’s correlation coefficient and multiple linear regression analyses. Results Four hundred and twelve participants were included in this study. Frail-VIG score and EQ-5D-3L value were negatively correlated (r = − 0.510; P

Abstract Background Planning population care in a specific health care setting requires deep knowledge of the clinical characteristics of the target care recipients, which tend to be country specific. Our area virtually lacks any descriptive, far-reaching publications about institutionalized older people (IOP). We aimed to investigate the demographic and clinical characteristics of institutionalized older people (IOP) ≥65 years old and compare them with those of the rest of the population of the same age. Methods Retrospective analysis (total cohort approach) of clinical and resource-use characteristics of IOP and non-IOP older than 65 years in Catalonia (North-East Spain). Variables analysed included age and sex, diagnoses, morbidity burden—using Adjusted Morbidity Groups (GMA, Grupos de Morbilidad Ajustada)—, mortality, use of resources, and medications taken. All data were obtained from the administrative database of the local healthcare system. Results This study included 93,038, 78,458, 68,545 and 67,456 IOP from 2011, 2013, 2015 and 2017, respectively. In this interval, an increase in median age (83 vs. 87 years), in women (68.64% vs. 72.11%) and in annual mortality (11.74% vs. 20.46%) was observed. Compared with non-IOP (p

Resumen: Objetivo: Consensuar una herramienta de valoración multidimensional/geriátrica rápida (VMGR), como sistema compartido y universal de valoración multidimensional de personas con multimorbilidad, fragilidad, complejidad o situación avanzada, para todos los profesionales del sistema de salud y social de Cataluña. Diseño: Consenso de profesionales en tres fases, combinando sesiones presenciales con trabajo telemático. Emplazamiento: Cataluña. Participantes: Se constituyó un grupo de 27 profesionales de carácter interdisciplinario representativo de los distintos ámbitos de atención. Método: Se han combinado las metodologías de Design thinking para el consenso inicial de características de la herramienta de VMGR (fase 1), con la metodología Lean Start-Up para el diseño de la nueva herramienta de VMGR (fase 2), que finalmente se testeó en un grupo de pacientes (fase 3). Resultados: En la fase 1 se consensuó que la herramienta de VMGR ideal debía permitir una valoración ad hoc de las personas, ser rápida y ágil (tiempo < 10 minutos), identificar las dimensiones alteradas mediante preguntas trigger y facilitar el diagnóstico de situación (idealmente cuantificado). En la fase 2 se elaboró el prototipo de una nueva herramienta de VMGR de 15 + dos preguntas (VIG-Express), finalmente testeada en 35 personas en la fase 3. Conclusiones: En los resultados preliminares, la herramienta VIG-Express parece facilitar una valoración multidimensional sencilla y rápida y la personalización de las intervenciones, así como una mirada única y un relato compartido entre los profesionales de los distintos ámbitos de atención. Serán necesarios más estudios para corroborar estos hallazgos. Abstract: Objective: To reach a consensus on an rapid multidimensional/geriatric assessment (RMGA) tool for all health and social professionals of Catalonia as a shared and universal system to assess patients with multimorbidities, frailty, complexity or advanced conditions. Design: Three-phase consensus of professionals, combining in-person sessions with telematics. Location: Catalonia. Participants: A group of 27 interdisciplinary professionals from different care settings. Method: The Design Thinking methodology for an initial consensus on the characteristics of the RMGA tool (Phase 1) has been combined with the Lean Startup methodology to create a new RMGA tool (Phase 2), and then tested in a group of patients (Phase 3). Results: In Phase 1, a consensus was reached that the perfect RMGA tool should allow for an ad hoc assessment of patients, be fast and flexible (

Objectives To assess the degree of frailty in older people with different advanced diseases and its relationship with end-of-life illness trajectories and survival.Methods Prospective, observational study, including all patients admitted to the Acute Geriatric Unit of the University Hospital of Vic (Spain) during 12 consecutive months (2014–2015), followed for up to 2 years. Participants were identified as end-of-life people (EOLp) using the NECPAL (NECesidades PALiativas, palliative care needs) tool and were classified according to their dominant illness trajectory. The Frail-VIG index (Valoración Integral Geriátrica, Comprehensive Geriatric Assessment) was used to quantify frailty degree, to calculate the relationship between frailty and mortality (Receiver Operating Characteristic (ROC) curves), and to assess the combined effect of frailty degree and illness trajectories on survival (Cox proportional hazards model). Survival curves were plotted using the Kaplan-Meier estimator with participants classified into four groups (ie, no frailty, mild frailty, moderate frailty and advanced frailty) and were compared using the log-rank test.Results Of the 590 persons with a mean (SD) age of 86.4 (5.6) years recruited, 260 (44.1%) were identified as EOLp, distributed into cancer (n=31, 11.9%), organ failure (n=79, 30.4%), dementia (n=86, 33.1%) and multimorbidity (n=64, 24.6%) trajectories. All 260 EOLp had some degree of frailty, mostly advanced frailty (n=184, 70.8%), regardless of the illness trajectory, and 220 (84.6%) died within 2 years. The area under the ROC curve (95% CI) after 2 years of follow-up for EOLp was 0.87 (0.84 to 0.92) with different patterns of survival decline in the different end-of-life trajectories (p

BackgroundThe number of days spent at home in the last six months of life has been proposed as a comprehensive indicator of high-value patient-centered care; however, information regarding the determinants of this outcome is scarce, particularly among the general population. We investigated the determinants of spending time at home within the six months preceding death.MethodsPopulation-based, retrospective analysis of administrative databases of the Catalan government. The analysis included adult (≥18 years) individuals who died in Catalonia (North-east Spain) in 2017 and met the McNamara criteria for palliative care. The primary outcome was the number of days spent at home within the last 180 days of life. Other variables included the cause of death, demographic characteristics, and socioeconomic status, stratified as very low, low, mid, and high level.ResultsThe analysis included 40,137 individuals (19,510 women; 20,627 men), who spent a median of 140 days (IQR 16-171) at home within the six months preceding death (women 140 [16-171]; men 150 [100-171]). Female gender was an independent factor of staying fewer days at home (OR 0.80 [95% CI 0.77-0.82]; pConclusionsOur results suggest that end-of-life care is associated with gender and socioeconomic inequalities; women and individuals with lower socioeconomic status spend less time at home within the last 180 days of life.

Abstract Background Demographic changes have led to an increase in the number of elderly frail persons and, consequently, systematic geriatric assessment is more important than ever. Frailty Indexes (FI) may be particularly useful to discriminate between various degrees of frailty but are not routinely assessed due, at least in part, to the large number of deficits assessed (from 30 to 70). Therefore, we have developed a new, more concise FI for rapid geriatric assessment (RGA)—the Frail-VIG index (“VIG” is the Spanish/Catalan abbreviation for Comprehensive Geriatric Assessment), which contains 22 simple questions that assess 25 different deficits. Here we describe this FI and report its ability to predict mortality at 24 months. Methods Prospective, observational, longitudinal study of geriatric patients followed for 24 months or until death. The study participants were patients (n = 590) admitted to the Acute Geriatric Unit at the at the University Hospital of Vic (Barcelona) during the year 2014. Participants were classified into one of seven groups based on their Frail-VIG score (0–0.15; 0.16–0.25; 0.26–0.35; 0.36–0.45; 0.46–0.55; 0.56–0.65; and 0.66–1). Survival curves for these groups were compared using the log-rank test. ROC curves were used to assess the index’s capacity to predict mortality at 24 months. Results Mean (standard deviation) patient age was 86.4 (5.6) years. The 24-month mortality rate was 57.3% for the whole sample. Significant between-group (deceased vs. living) differences (p

Introduction: Drug therapy in older patients is becoming a worldwide concern due to the progressive increase in the number of drug prescriptions and the difficulties in ensuring appropriate prescribing. Appropriate prescribing in these patients is a complex problem that cannot be solved by simply applying clinical practice guidelines (CPG). Patients with multimorbidity usually show an evolution towards a progressive clinical, functional or cognitive impairment, which, in most cases, results in a limited life prognosis. In this scenario, drug therapy, which could have been appropriate in the past, can eventually become inappropriate as a disease progresses. Frail older patients are more sensitive to inappropriate prescribing (IP), as they suffer a reduction in their ability to tolerate medications due to changes in pharmacokinetics and pharmacodynamics. Consensus on the best procedure to optimize prescribing has not yet been established. In this context, we propose the use of a model which combines both the clinical judgment and the scientific evidence in a pragmatic and systematic approach. The main objective of this model is to identify potentially IP in a group of older patients and to optimize them according to care goals of each patient. Care goals are established through the application of the Patient-Centered Prescription Model, which is based on a shared decision-making process including patient, physicians and a clinical pharmacist. Description of practice: Each patient's pharmacotherapeutic plan is assessed through application of the Patient-Centered Prescription Model[1,2]. In brief, this is a systematic three-step process carried out by a multidisciplinary team made up of geriatricians and a clinical pharmacist: Step 1 - Patient Centered Evaluation The main objective of this step is to determine the global care goal of each patient: survival, improving or maintaining function or symptomatic control[3]. A holistic review of the patient, by means of a Comprehensive geriatric assessment, determines his care goal. Professionals and patients establish a cooperative process to identify needs and agree on objectives[4]. This first evaluation sets the stage for the second and third steps. Step 2 - Diagnosis Centered Evaluation: Health problems of the patient along with the drugs prescribed for each diagnosis are listed. Drug purpose should fit with the main care goal previously agreed upon with the patient. Special attention is paid to prevalent disease states (Diabetes Mellitus (DM2)[5], arterial hypertension[6], dyslipidemia[7], Pain[8][9] and end of life situation[3,10]). Step 3 - Medication centered assessment: Based on the goals of care derived from step 1, the purpose of step 3 is to assess the indication of high risk medications (NSAID, antiplatelets, anticoagulants, hypoglycemics, insulin, digoxin and opioids[11]) or high risk combinations (risk of drug-drug or drug-disease interactions)[12] Proposed therapeutic plan: At the end of the process, as an integrated care approach, an individualized treatment plan is sent (or discussed by phone) for review and agreement with primary care. Key findings: These are the results of three descriptive observational studies of patients admitted to an Acute Care Elderly (ACE) Unit, in three periods from 2012 to 2015. 382 patients were included. Average age of 86.7 years. 40% of all patients met the criteria for advanced chronic conditions (ACC). At admission, median of medications per patient was 7, no differences between patients with ACC and the rest. 80% of patients met the definition for polypharmacy, no significance with patients with ACC. 33% of patients with ACC took 10 or more medications. 20% of total of patients had 2 or more iatrogenic medications prescribed, no differences between patients with ACC and the rest. Overall, almost 40% of patients presented with an indication of at least one IP. Patients with ACC were significantly more likely to have IP (47.2% versus 34.7%) (p<0.05). During admission, drug therapy regimens were modified in 93.44% of cases with IP. Prevalence of polypharmacy decreased significantly and, the prevalence of patients with ACC with 10 or more medications decreased to a half (p<0.05). Analizing patients with advanced dementia, 24.80% of their medications were for prevention, of which 76.2% were for primary prevention. At discharge, two-thirds (66.85%) of them were discontinued. Highlights: The proposed methodology represents an initial approach encompassing evidence from multiple fields on the appropriateness of prescribing in the elderly and facilitating application of evidence in the routine clinical setting. Patient is the center of attention and he is an active member in the decision-making process. Conclusions: Patients with advanced chronic conditions do not have a prescription according to their needs. The Patient-Centered Prescription Model is a framework that helps minimize IP in a high-risk group older patients through a suitable approach to individualize a pharmacotherapeutic plan. It is applicable in other healthcare settings, such as nursing-homes or community care. [ABSTRACT FROM AUTHOR]

Context: In most developed countries, there is an increase of frail elderly people who are frequent users of health and social resources, often in an unplanned way. Recently, because of sustainability, there has been a significant reduction in acute hospital beds. These two phenomena have led to a saturation of the emergency services and increased the need for a new organizational model. This problem needs to be approached in a systemic way, by viewing it as a problem of the health system as a whole, not just as issue for emergency departments. To address the growing demands on the health system, the government has devised a system of pathways through the health service for the most frequently occurring medical needs of the population, for example, diabetes and, in relation to this paper, a complexity pathway. This involves the identification of patients and the development of treatment plans, and at the same time the reorganization of services to provide care in the most coordinated way possible. This paper aims to describe how an emergency service has been reorganized in the context of a complexity pathway through the health system and what impact it has had on the rate of hospitalizations and alternatives to hospitalization. Organizational changes: - Proactively detect patients who may be candidates for alternatives to hospital from the emergency department: patients already marked as complex from the community (use of territorial information systems), patients from nursing homes, patients who consult for a geriatric syndrome and patients aged over 85. - Involve all emergency service professionals through training in how to approach this demographic group. - The hospital management believes it is a strategic project. - Introduction of a short geriatric assessment in casualty departments. - Having a nurse practitioner who participates in the evaluation and management of cases and in coordinating all related intermediate care. - Having access to consultations with geriatric professionals from the acute geriatric unit or intermediate care units. Results in patients. - Up to October 2015, 437 patients were referred from emergency to intermediate care resources. 302 in the programme of sub-acute care and 135 in the hospital at home programme. - These patients are on average 81 years old, have a Barthel baseline of 61 and a high prevalence of geriatric syndromes. - The patients referred to sub-acute care had lower Barthel baseline and were classified as MACA (advanced chronic disease). Dementia diagnosis was more common. - This project has reduced the admissions in acute care of persons over 85 by 15% during the last two years. Conclusions: - Many patients were referred to hospitalization alternatives after applying this methodology. - The alternatives to hospitalization from casualty are allocated to people over 80 with a high level of frailty (geriatric syndromes, disability, advanced disease situation). - Patients have different characteristics according to which alternative they are referred to. - Hospital admissions of people > 85 to the acute hospital unit were reduced. - The participation of the nurse practitioner is the key to achieve good coordination with intermediate care. [ABSTRACT FROM AUTHOR]