Table 4. Context of included studies.

Study	Country	Strength of primary care orientation (of country)*	Population	Study design (n participants)	Study length (months)	Brief description of model	Extracted outcomes for meta-analysis
Beland 2006a [57]; Beland 2006b [58]	Canada	intermediate	Elderly & functionally disabled	RCT; n = 1309	22	Community-based MDTs with full clinical responsibility for delivering and coordinating services. 24-hour availability via phone. Actively followed patients through care trajectory.	Utilisation (primary/secondary care)
Bernabei 1998 [59]	Italy	high#	Elderly & receiving home health services/assistance	RCT; n = 199	12	MDT-designed care plan following assessment by GP/case manager. Case manager followed-up every two months, and constantly available to deal with problems and monitor provision of services.	Mortality, Self-reported health status, Utilisation (primary/secondary care)
Bird 2010 [60]	Australia	intermediate	Frequent presenters for COPD/CHF	CBA; n = 124 (COPD)/n = 89 (CHF)	11	Patients allocated to disease-specific stream based on presentations. Results of initial case facilitator assessment discussed at case conference with MDT. Education, self-management, and coordination focus. Follow-up mostly at home	Mortality, Utilisation (secondary care)
Boult 2008 [61]; Leff 2009 [62]; Boyd 2010 [63]; Boult 2011 [64]; Boult 2013 [65]	USA	low	Elderly & high-risk multimorbid	cRCT; n = 904	32	Nurse responsible for assessing, planning care, monitoring, coaching self-management, coordination of services, and education for patient and family. Helped by team of physicians.	Total cost of services, Mortality, Patient satisfaction, Self-reported health status, Utilisation (primary/secondary care)
Boyd 1996 [66]	USA	low	Elderly & chronically ill	nRCT; n = 54	12	Community-based, integrating case management in patient’s everyday life, with case manager available to monitor the patient’s chronic illness(es). Developing care plan, coordinating services, and providing counselling support.	Mortality
Burns 1995 [67]; Burns 2000 [68]	USA	low	Frail elderly	RCT; n = 98	24	Consistent involvement of MDT (GEM team). Initially assess patient and provide ongoing management. Most appropriate team member for given patient served as main liaison.	Mortality, Self-reported health status, Utilisation (primary/secondary care)
Coburn 2012 [69]	USA	low	Elderly & chronically ill	RCT; n = 1736	60	Patients risk-stratified within intervention. Regardless of strata, nurse developed an individualised care plan. Group interventions were also provided by the care managers. Nurses collaborated with other healthcare professionals when required.	Mortality
Counsell 2007 [70]; Counsell 2009 [71]	USA	low	Low income elderly	RCT; n = 951	24	Care plan developed in collaboration with MDT. Weekly team meetings to review team successes and problem-solve barriers to implementation. At least monthly home-based care management supported by an electronic medical record and web-based tracking system.	Total cost of services, Mortality, Patient satisfaction, Self-reported health status, Utilisation (secondary care)
Dalby 2000 [72]	Canada	intermediate	Frail elderly living in the community	RCT; n = 142	14	Nurse-led comprehensive assessment. Care plan developed in conjunction with primary physician. Follow-up visits and calls as needed. Nurse coordinates further community services	Mortality, Utilisation (primary/secondary care)
De Stampa 2014 [73]	France	low	Frail elderly	CBA; n = 428	12	Two-person team responsible for patient’s care trajectory. The primary care manager developed care plan, ongoing role of physician to collaborate and share information. Support as needed from geriatricians.	Self-reported health status, Utilisation (secondary care)
Dorr 2008 [74]	USA	low	Elderly & chronically ill	nRCT; n = 3432	24	Case management aimed at addressing social, cognitive, and functional needs. Assisted by specialised IT software including structured protocols and guidelines. Co-creation of care plan with patients.	Mortality, Utilisation (secondary care)
Enguidanos 2006 [75]	USA	low	Frail elderly	RCT; n = 452	12	Study compares 4 strategies of care. Telephone case management (single case manager); Geriatric care management (GCM) (MDT involvement in care plan); GCM with purchase of service capability (addition of $2000 of designated paid services within first 6 months); Information and referral assistance (most basic, acts as control group).	Utilisation (primary/secondary care)
Fan 2012 [76]	USA	low	Frequent presenters for COPD	RCT; n = 426	12	Initial individual educational programme, needs assessment, and an overview of COPD. Reinforced during group session, and with follow-up phone calls. Individualised plan for flare-ups, including prescriptions for prednisone and antibiotic.	Mortality, Patient satisfaction, Self-reported health status, Utilisation (secondary care)
Fitzgerald 1994 [77]	USA	low	Inpatient medical service users	RCT; n = 668	12	Included instructing patients about their medical problems, facilitating access to usual care, and identifying and fulfilling unmet social and medical needs with standard or alternative sources of care. Periodic assessment of medical and social needs. Coordination of all appointments for patient. 24-hour telephone access	Mortality, Utilisation (primary/secondary care)
Fordyce 1997 [78]	USA	low	Frail elderly	RCT; n = 1090	36	Yearly health, functional, and social evaluation. Weekly team meetings where nurse presented cases for review. Medical-functioning profile worked up for each patient, acting as indication of intensity of follow-up, as needed. Follow-up mostly by telephone.	Utilisation (secondary care)
Gagnon 1999 [79]	Canada	intermediate	Frail elderly	RCT; n = 427	10	Coordination of all healthcare providers and implementation of a responsive plan of care. Monthly phone calls, and a home visit every 6 weeks were the minimum standard. Additional contacts when required. Specialist consultation available to nurses for complicated cases.	Patient satisfaction, Self-reported health status, Utilisation (secondary care)
Gravelle 2007 [80]	UK	high	Frail elderly	CBA; n = 7757 (practices)	48	Assessment, using structured assessment tools, a physical examination, which resulted in an individualised care plan. Patients were then monitored at a frequency determined by their classification of risk.	Mortality, Utilisation (secondary care)
Hogg 2009 [81]; Gray 2010 [82]	Canada	intermediate	Older & at-risk of adverse outcomes	RCT; n = 241	18	Nurses and pharmacist co-located at family practice, but delivered care almost exclusively at patient’s home. Team-developed care plan. 22 patients also received a tele-health system for remote monitoring.	Total cost of services, Self-reported health status, Utilisation (primary/secondary care)
Kruse 2010 [83]	USA	low	Elderly & chronically ill, at-risk for catastrophic illness	nRCT; n = 379	60	Assessed patient’s needs, provided education, coordinated referrals, provided first-access care and follow-up care following visits to doctor/hospital on the telephone.	Mortality, Utilisation (primary/secondary care)
Leung 2004 [84]	Hong Kong	intermediate^	Community-dwelling frail elderly	RCT; n = 260	6	Regular home-visits and telephone consultations. Care plan designed in discussion with patient and caregiver. Coordination of health and social services through referral plus case conference. Monitoring of health and hospitalisation patterns via computer programme. Counselling, health education, and supportive group services.	Self-reported health status, Utilisation (primary/secondary care)
Levine 2012 [85]	USA	low	Elderly & multimorbid, at-risk for hospitalisation	RCT; n = 298	12	Included early identification and treatment of illness exacerbation, patient-specific health education, self or caregiver management of disease, and advance care planning and other psychosocial issues. Team worked closely at all stages.	Total cost of services, Patient satisfaction, Utilisation (primary/secondary care)
Martin 2004 [86]	New Zealand	intermediate+	Acutely deteriorating COPD patients	RCT; n = 93	12	Generic care plan was individualised and signed off. Supplies of antibiotics and prednisone made available. Copies of plan held by each potential provider of care. Routine support and further education available.	Utilisation (primary/secondary care)
Metzelthin 2013[87]	The Netherlands	high	Frail elderly	cRCT; n = 346	24	Core team (GP and nurse) cooperate closely with other health professionals as needed. Initial home-visit and assessment, meeting to design care plan, and treatment starts with protocol offering recommendations and guidelines.	Self-reported health status
Morishita 1998 [88]; Boult 2001 [89]	USA	low	Elderly & high-risk	RCT; n = 568	18	Consistent involvement of MDT (GEM team). Specialised GEM clinic introduced, where patients were followed-up. Individual team members saw patients approximately monthly, met to discuss. Regular telephone calls, and available 24-hours on telephone service	Total cost of services, Mortality, Patient satisfaction, Self-reported health status, Utilisation (primary care)
Newcomer 2004 [90]	USA	low	High-risk elderly	RCT; n = 3079	12	Patients triaged by risk category after initial assessment. Predominant method of contact was telephone, supplemented by monitoring utilisation. Nurse case manager distributed educational material and advice, coordinated services, but no direct role in treatment management.	Self-reported health status, Utilisation (primary/secondary care)
Ploeg 2010 [91]	Canada	intermediate	Elderly & at-risk of functional decline	RCT; n = 719	12	Nurse-led comprehensive initial assessment, collaborative care planning, health promotion, and referral to community health and social support services. Assessments at baseline, 6 and 12 months. Additional health education and referrals to other health services.	Total cost of services, Mortality, Self-reported health status, Utilisation (primary/secondary care)
Rodenas 2008 [92]	Spain	high	Elderly & receiving home care	RCT; n = 152	12	Direct interaction with the patients was carried out by a MDT. The team took charge of: 1) assessing individual needs 2) designing and starting individual care itineraries 3) benefit quality assurance, and 4) monitoring and on-going review of the strategy. Extra health and social care resources were also available for the intervention group.	Patient satisfaction, Utilisation (primary/secondary care)
Rubenstein 2007 [93]	USA	low	High-risk elderly	RCT; n = 793	36	Initial telephone assessment by physician assistant case manager. Some patients referred for further assessment and an interdisciplinary care plan at a geriatric assessment unit. Coordination of follow-up by phone, each patient mailed a copy of the care plan.	Self-reported health status, Utilisation (secondary care)
Schraeder 2001 [94]	USA	low	Community-dwelling elderly	RCT; n = 941	24	Team's goal was to provide enhanced primary care by providing assessments, flexible home office visits, detailed care planning, routine telephone monitoring, and coordination and procurement of supportive services. Nurse and care assistant co-located.	Total cost of services, Mortality, Utilisation (secondary care)
Schraeder 2008 [95]	USA	low	Community-dwelling, chronically ill elderly	nRCT; n = 677	36	Intervention emphasised collaboration between physicians, nurses and patients, risk identification, comprehensive assessment, collaborative planning, health monitoring, patient education, and transitional care. Nurse and care assistant co-located.	Utilisation (secondary care)
Shannon 2006 [96]; Alkema 2007 [97]	USA	low	Elderly & high utilisers	RCT; n = 781	12	Telephone-based management to coordinate services bridging medical and social care. Focus on referrals. Monthly follow-up calls.	Mortality, Utilisation (primary/secondary care)
Sledge 2006 [98]	USA	low	Recent high use of inpatient services	RCT; n = 96	12	PIC intervention consisted of two components: 1) a comprehensive interdisciplinary medical and psychosocial assessment (2–3 hours on first visit), and 2) follow-up ambulatory case management for 1 year. Involvement differed by need, but minimum monthly call.	Total cost of services, Mortality, Patient satisfaction, Self-reported health status, Utilisation (primary/secondary care)
Stuck 2000 [99]	Switzerland	low#	In-home visits for disability prevention	RCT; n = 791	36	Annual nurse-led comprehensive assessments. Cases discussed with geriatrician and recommendations developed. In-home follow-up visits every 3 months. Nurses also provided health education, encouraged self-care, and attempted to improve communication with the physician. Interdisciplinary team available to discuss complex patients.	Mortality, Self-reported health status, Utilisation (secondary care)
Sylvia 2008 [100]; Boyd 2008 [101]	USA	low	Community-dwelling, chronically ill, elderly	nRCT; n = 127	6	At-home assessment, evidence-based care plan, promotion of self-management, monthly monitoring, coaching on healthy behaviours, coordination of transitions in care, and facilitating access to community resources.	Total cost of services, Patient satisfaction, Utilisation (primary/secondary care)
Toseland 1996 [102]; Toseland 1997 [103]; Engelhardt 1996 [104]; Engelhardt 2006 [105]	USA	low	Frail elderly	RCT; n = 160	48	Primary functions of the GEM team included: initial comprehensive assessment; development of a care plan; implementation of the care plan; periodic reassessment; monitoring and updating the care plan, and; referral to and coordination with other health and social service providers. Weekly team meetings to discuss.	Total cost of services, Mortality, Patient satisfaction, Self-reported health status, Utilisation (primary/secondary care)
van Hout 2010 [106]	The Netherlands	high	Community-dwelling frail elderly	RCT; n = 651	18	Assessment of health and care needs, recommended interventions based on guidelines, individually tailored care plans (copy left at patient’s home for other care workers to see/add to). Home visits at least 4 times a year.	Mortality, Self-reported health status, Utilisation (secondary care)

* Source: Starfield et al 2002 [31], unless otherwise stated

^# Source: Macinko et al 2003 [107]

⁺ Source: Grant et al 1997 [108]

^{^} Source: Fry & Horder 1994 [109]