Post-acute Care for Patients With Frailty

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