The University of Ottawa and Élisabeth Bruyère Research Institute are conducting a study of preventive care for frail patients at risk of functional decline. At risk patients are assigned by chance to continue receiving their standard care from their family physician or receive additional care from a nurse practitioners and a pharmacist. In collaboration with the family physician, they develop an individualized care plan, a treatment and management road plan, for each patient, which they implement over the study period of one approximately year. The objective of the study is to compare the effectiveness of the model of care that includes the nurse practitioners and pharmacist against standard care in preventing functional decline, to determine the acceptability of this model of care to patients, their caregivers and the medical team, and to evaluate the cost implication of the program.

Inclusion Criteria:

• 50 years and over
• 'At Risk' by having one or more of the following: a. Visits to emergency dept within the past 6 months; b. Admission to hospital for a medical problem in past 6 months; c. High service use profiles; d. Polypharmacy; e. Other high risk factors
• Capable of giving informed consent
• Able to use the Care Companion technology

Exclusion Criteria:

• Cognitive impairment such that they cannot give informed consent
• Unable or unwilling to use the telehomecare equipment
• Unlikely to tolerate the intensive intervention
• Language or cultural barriers
• Being acutely ill or having an unstable condition on entry to the study