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 |