Development, validation and impact of an alert management system using social workers' observations and machine learning algorithms to predict 7-to-14-day alerts for the risk of Emergency Department (ED) Visit and unplanned hospitalization. Multi-center trial implementation of electronic Home Care Aides-reported outcomes measure system among patients, frail adults \>= 65 years living at home and receiving assistance from home care aides (HCA).
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Unplanned Hospitalization rate
Timeframe: through study completion, an average of 1 year
Event-free survival (EFS)
Timeframe: through study completion, an average of 1 year
Impact on older adults and relatives' quality of life (European Quality of Life 5 Dimensions and 3 Lines scale)
Timeframe: through study completion, an average of 1 year
Cost-effectiveness
Timeframe: through study completion, an average of 1 year