[Monitoring a home care cohort].

Objectives: To evaluate home care by primary care teams for people over 65 years old with chronic conditions, in order to identify improvement opportunities. To identify patient and care variables associated with cognitive and functional impairment, nursing home admission, attendance at casualty units, hospital admission and death.

Design: Analytic study of the follow-up of a cohort for 3 years.

Setting: Primary health care teams in Catalonia, Spain.

Patients: One thousand three hundred patients over 65 with chronic pathologies and cared for by home care programmes in Catalonia.

Main Measurements: The following will be recorded annually: health status (Charlson, Barthel, Pfeiffer, Braden, and Gijón), data on the carer (Zarit), care received (social and health), self-perception of health (SF-12), Casualty attendance, short-term admissions and the final results, i.e. death or definitive admission to a nursing home or hospital. The statistical analyses will be based on logistic regression and a survival analysis.

Conclusions: The study should reveal patient characteristics with prognostic value, as well as identify the social and health factors related to better survival and lower consumption of health and social resources.