Table 1 Inclusion and exclusion criteria

Inclusion:

• Age 75 years and over and listed as general practice patient

• Living at home

• Frail: Self reported Health score in the worst quartile of at least two of six COOP-WONCA charts (scoring range: 1, excellent, to 5 very bad): Overall health ≥4; Physical fitness ≥5; Changes in health ≥4; Daily activities ≥4; Mental health ≥3; Social activities ≥3

Exclusion:

• Terminally ill as determined by PCPs

• Persons with dementia symptoms according to MMSE or 7-minute screen

• Living in residential homes.

• Participating in other research projects