AdvantAGE: Implementation and Evaluation of an Interprofessional Tranistional Care Model for Frail Older Adults

Inclusion Criteria: * Currently admitted to the acute or rehabilitation ward of University Department of Geriatric Medicine * Reside in Basel-Stadt * Possess the ability to speak and comprehend the German language * Scheduled to be discharged to their home * 65 years or older * Identified by a clinician as having a high risk of deterioration due to frailty Additionally, participants must meet at least one of the following criteria: * diagnosed with a complex chronic disease requiring support in self-management and disease management, or * facing socially challenging situations such as living alone without a supportive network or lacking a GP, or * admitted for an acute illness with a brief hospital stay (e.g., infection, cardiac decompensation) and need support in self- and disease management, and continuity of the therapy plan, including close monitoring. Exclusion Criteria: * residing in a nursing home or being newly admitted to one * lacking informal caregivers and exhibiting severe cognitive impairment (MMS ≤23) * scoring \<50 on the motoric domain of the Functional Independence Measure (FIM) * having a psychiatric disorder that significantly impacts their ability to manage daily life at time of the discharge