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一、65歲以上
二、具一種或多種老年症候群,且有明確治療目標者,如下:
1. 多重用藥
2. 跌倒
3. 譫妄症
4. 營養不良 5.壓瘡 6.尿失禁 7.憂鬱
4. 營養不良
5.壓瘡
6.尿失禁
7.憂鬱
三、或因多重身體、功能或合併社會心理問題,需要跨領域團隊介入的病患。