the intervention group will receive individualized interventions.

The control group will receive routine diagnosis and treatment

First, the underlying causes of the patient's frailty should be analyzed. Individualized goals should be established using Goal Attainment Scaling (GAS), followed by implementation of tailored measures. For patients presenting with malnutrition or mood-related disorders, comprehensive nutritional and psychological assessments must be conducted, with subsequent nutritional support or pharmacological treatment initiated when clinically indicated.

The patients of the intervention group with poor physical function would receive exercise prescription tailored to the subjects' physical ability from a trained specialist. For Participants requiring exercise-based interventions, a moderate and gradually increasing intensity exercise regimen home-basethree times a week, over a 12-week duration will be administer under telehealth-based monitoring.

A pool of potential goals was developed by the research team based on the International Classification of Functioning, Disability, and Health (ICF). Each participants selected three goals through collaborative discussions among physicians, the individual, and caregivers. Participants were actively involved in the goal-setting and goal-rating process with the guidance of the research team. Participants also should weigh their goals by importance and difficulty at baseline. Goals were weighted by multiplying the importance level and the anticipated difficulty level, both graded on a 0-3 scale. For each goal, create a 5-point scale(-2 to +2) to describe potential outcomes: -2: Much worse than expected;-1: Somewhat worse than expected; 0: Expected level of success;+1: Somewhat better than expected; +2: Much better than expected. An aggregated T score with a mean of 50 and an SD of 10 was obtained.The extent to which goals are achieved is standardised into a T score by the formula