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 |