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Inclusion:
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• Age 75 years and over and listed as general practice patient
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• Living at home
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• 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
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Exclusion:
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• Terminally ill as determined by PCPs
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• Persons with dementia symptoms according to MMSE or 7-minute screen
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• Living in residential homes.
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• Participating in other research projects
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