"Healthy ageing" is not limited to the absence of disease, but implies the "development and maintenance of the functional skills that enable the elderly to enjoy a state of well-being": (for example : the ability to walk, go out, engage in leisure activities, memorize...) It is interesting to study whether the implementation of a Personal Health Plan (PHP) in a Multiprofessional Health Home improves the quality of life of frail elderly people.
Patient ≥ 70 years
Autonomous patient (ADL ≥ 5)
Patient identified as frail according to the Gérontopôle de Toulouse GFST grid
Patient whose primary care physician is in the MSPs of Charleval or Romilly sur Andelle for the intervention group, and in the MSPs of Gaillon and Pont de l'Arche for the control group.
Hospital geriatric follow-up
Geriatric assessment already carried out
Person deprived of liberty by an administrative or judicial decision, or placed under court protection / sub-guardianship or curatorship
History of illness or psychological or sensory abnormality likely to prevent the subject from fully understanding the conditions required for participation in the protocol, or from giving informed consent.
University Hospital, Rouen
Lead sponsor
Ministry of Health, France
Collaborator