INSPIRE: Feasibility of a Community-based Integrated Care Model for Older Adults Living at Home

"i) Screening of older people for risk of frailty using a frailty screening tool, to identify the appropriate care they will require:~* Older adults with low risk of frailty will receive health promotion and preventive care from the Information and Advice Center nurse and/or social worker.~* Older adults at risk will receive the following:~ii) a Comprehensive Geriatric Assessment (CGA) delivered by the Information and Advice Center nurse and social worker over the course of multiple appointments, to identify the health and social care needs and goals of the older person; iii) Development of an individualized care plan by a multidisciplinary team, which will include evidence-based interventions and be coordinated by the Information and Advice Center nurse and/or the social worker; and iv) follow-up depending on the situation of each older person, and adaptation of the individualized care plan, as needed."