Acute illness could be enormous stress for frail people. Combining comprehensive geriatric assessment and multifactorial intervention has positive effects on frail community older adults. However, few studies investigated the effects of post-acute care (PAC) in frail older patients who just recovered from acute hospitalization. This study aimed to evaluate the effects of PAC on frail older adults in Taiwan.

Frail patients aged >= 75 were recruited and divided into PAC or control groups. The PAC group received comprehensive geriatric assessment (CGA) and multifactorial intervention for two to four weeks. The control group received CGA only. The primary outcomes were 90-day emergency room visits, readmissions, and mortality after PAC.

Inclusion Criteria:

1. Mild to severe frailty identified by the Clinical Frailty Scale
2. Age ≥ 75 years
3. Diagnosis with Parkinson's disease, dementia, chronic obstructive pulmonary disease, or chronic kidney disease stage three or worse
4. Acute hospital stays between 3 to 30 days with deconditioning
5. Stable medical condition with no need of intensive care, laboratory examination, or oxygen dependence

Exclusion Criteria:

1. Refused to participate in the program
2. Candidate for other post-acute care programs (i.e. stroke, traumatic neurological injury, or fracture)
3. Unable to cooperate with the program due to mental or cognitive impairment
4. Long-term ventilator-dependence
5. Long-term bed-ridden status (> 6 months)
6. Diagnosed as end of life and in need of palliative care
7. Diagnosed as major illness (i.e. end-stage renal disease) and in need of frequent inpatient treatment ( > 3 times over recent 6 months)
8. Institutional residents
9. Home medical care participants