Patients admitted to acute ordinary wards in a medical center in Southern Taiwan from an elder-integrated outpatient department or emergency room from January 2017 to December 2017 were included if they met the following criteria: (i) age 65 years or older, (ii) Barthel index score ≦60 and (iii) with at least one of the following geriatric syndromes: unsteady gait or easy-to-fall ( falls ≧ 2 in last 1 year), malnutrition with Mini Nutritional Assessment-Short Form screening score < 12, urinary incontinence, pressure sores, dementia, delirium, depression, polypharmacy (≧8 medications), and excessive utilization of healthcare facilities (admission≧2, visit Emergency≧2, or visit outpatient department≧12 in one month). Patients were excluded if they were in a vegetative state, under palliative care or terminally ill and suffering from acute illness needing to be transferred to or cared for in the Intensive Care Unit.

Human participant approval was obtained from the Chang Gung Medical Foundation Institutional Review Board before data collection. Participants were recruited from the ordinary wards by research assistants who screened the admission list every morning if they met the inclusion criteria. Then, the detail of the research was explained to the patients and families. They were allowed to choose to be in the control group or the intervention group. After the participants and or family agreed, informed consent was signed. For those who were cognitively impaired or suffered from dementia, informed consent was signed by their relative or partner. For the intervention group, a geriatric physician was consulted and recommendations were made by the geriatric consultant after a complete geriatric assessment. Besides the geriatric physician, the investigator's multidisciplinary team included a social worker, nutritionist and physical therapist. In the control group, the participants only received routine hospital care and no geriatric physician was consulted.

Participants were recruited from the ordinary wards by research assistants who screened the admission list every morning if they met the inclusion criteria. Then, the detail of the research was explained to the patients and families. They were allowed to choose to be in the control group or the intervention group. After the participants and or family agreed, informed consent was signed. For those who were cognitively impaired or suffered from dementia, informed consent was signed by their relative or partner. For the intervention group, a geriatric physician was consulted and recommendations were made by the geriatric consultant after a complete CGA. The CGA includes the assessment of depression, dementia, physical performance of Activity of Daily Living (ADL) and nutrition using Geriatric Depression Scale (GDC-15), Mini-Mental State Examination (MMSE), Barthel Index (BI), and Mini Nutritional Assessment-Short Form (MNA®-SF) respectively. Besides the geriatric physician, our multidisciplinary team included a social worker, nutritionist and physical therapist. In the control group, the participants only received routine hospital care and no geriatric physician was consulted. The case manager nurse filed the participant's baseline data and clinical problems. After discharge, the participant's condition was assessed via telephone in the first, third and six months after discharge.

Inclusion Criteria:

(i) age 65 years or older, (ii) Barthel index (BI) [18] score ≦60 and (iii) with at least one of the following geriatric syndromes: unsteady gait or easy-to-fall ( falls ≧ 2 in last 1 year), malnutrition with Mini Nutritional Assessment-Short Form (MNA®-SF) screening score < 12, urinary incontinence, pressure sores, dementia, delirium, depression, polypharmacy (≧8 medications), and excessive utilization of healthcare facilities (admission≧2, visit Emergency≧2, or visit outpatient department≧12 in one month)-

Exclusion Criteria:

Patients were excluded if they were in a vegetative state, under palliative care or terminally ill and suffering from acute illness needing to be transferred to or cared for in the Intensive Care Unit.