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70 years of age and over
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The patient lives independently or in a home for the aged
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The patient has a health problem that was recently presented to the GP by the patient or informal caregiver
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The request for help is related to the following problem fields: cognitive disorders, behavioural and psychological symptoms of dementia, mood disorders, mobility disorders and falling, or malnutrition
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The patient/informal caregiver and GP have determined a goal they want to achieve
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Fulfil one or more of these criteria: MMSE (Mini Mental State Examination) equal to or less than 26, GARS (Groningen Activity Restriction Scale) equal to or greater than 25 or MOS-20/subscale mental health equal to or less than 75
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Exclusion criteria
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The problem or request for help has an acute nature, urging for action (medical or otherwise) within less than one week
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The problem or request for help is merely a medical diagnostic issue, urging for action only physicians (GP or specialist) can offer
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MMSE < 20 or proven moderate to severe dementia (Clinical Dementia Rating scale [CDR] > 1, 0) and no informal caregiver (no informal caregiver is defined as: no informal caregiver who meets the patient for at least once a week on average)
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The patient receives other forms of intermediate care or health care from a social worker or community-based geriatrician
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The patient is already on the waiting list for a nursing home because of the problem the patient is presented with in our study
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Life expectancy < 6 months because of terminal illness
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