The demographic shift towards a progressive aging of the population represents an unprecedented challenge for Western societies and for the sustainability of health and social systems.

Hypotheses: A complex, multi-component intervention based on integrated home care, facilitated by technological tools and focused on the frail person with complex needs (ADMIT Program):

• Will increase at least 5% of the days spent at home compared to usual care
• Will reduce exacerbations or health or social crisis at home
• Will improve the quality of life and well-being of users and their informal caregiver
• Will improve the experience of the people cared for, their caregivers and professionals in the health and social systems

Main objective: To evaluate the effectiveness of the ADMIT program in increasing the % of days at home of frail elderly people compared to usual practice.

Secondary objectives:

To evaluate the effectiveness of the ADMIT program compared to usual care to reduce exacerbations or situations of crisis that motivate emergency care or hospitalizations.

To evaluate the incremental cost-utility ratio of the ADMIT program in relation to usual practice, exploring different time horizons and different scenarios of population scalability.

To evaluate the experience of the people treated, their informal caregivers and professionals.

To identify the determinants of change and contextual factors of the program implementation process

Methodology:

Hybrid evaluation model that allows evaluating the process, effectiveness, safety and cost-utility while implementing the intervention in real life. Mixed methods, typical of implementation science, will be used, with different stages: First stage: co-creation of the care model and the technological platform with the participation of users and professionals Second stage: evaluation of the process, results and experience through a pragmatic randomized controlled trial with a batched stepped wedge design and comparison with a parallel "external" control group, matched using propensity score techniques.

Applicability and Relevance: The ADMIT program is aligned with the current trend and the shared interest of evolving towards integrated social and health care, keeping people with complex needs in their homes for as long as possible and with the best possible quality of life. The ADMIT project is an implementation project supported by the Catalan Health Department and the Integrated Care Agency. The technological platform that will be co-created and piloted is expected to be adopted by Catalan Health Department for its scaling up in the territory.

Inclusion Criteria:

• Living at home AND
• Adjusted Morbidity Group = 3 or 4 or high risk OR Complex or Advanced frailty or chronicity OR Home health care program; AND
• Dependent for the basic daily activities OR Social complexity (SSM-CAT positive) OR Dependency grade= 1, 2 or 3 OR Lack of social support OR Home social care program OR Living alone

Exclusion Criteria:

• Living in a nursing home
• Unable to make decisions about care (either by the patient or the caregiver)
• Person with needs that exceed the coverage of the program
• Not providing informed consent