As the aging population increases, preventing and decreasing disabilities become a critical issue for the health care system. Previous researches have shown that preventive community-based nursing services for older adults could achieve important health benefits at a relatively low cost. However, many frail and pre-frail older adults living in communities cannot get enough attention from current health care system. The role and function of nurses should be expanded to provide more comprehensive family-oriented care to improve health outcomes of older adults in Taiwan. The objectives of this study are:

1. Understand the difficulties and solutions for nurses providing community-based services in order to expand their better role and function.
2. Develop a cultural sensitive community advanced nurse service model for Taiwan in health care system.
3. Explore the effectiveness of community health programs by nurses for frail or pre-frail older adults in community.

Focus groups and literature review will be used to achieve the first and second study objectives. A single centre randomized controlled trial will be used in this study to achieve the third study objective. Two hundred and twenty people aged 65 and over who meet the Fried definition of frailty and pre-frailty will be recruited from the clinic of a hospital. Participants will be followed for a 6-month period. Frailty, quality of life, satisfaction to the services, hospitalizations and admissions to nursing care facilities will be measured and compared between experimental group and control group. This research is an important step in the examination of a new approach to the community older people by nurses. The study results will provide the evidence data to recommendation for related policy making in the future.

Inclusion Criteria:

• 65 years and above, frail and pre-frail older adults, living in communities

Exclusion Criteria:

• Cognitive impairment.