The intervention: After baseline assessment the intervention group receive an interdisciplinary assessment based on CGA, tailored to each participant for 24 months. The first visit is either at the hospital or in the patient's home, depending on the participant's condition and ability to travel. The multidisciplinary teams consisting of physician, nurse, pharmacist, physiotherapist and occupational therapist with access to more competences if needed. The team works according to CGA, and has the primary and continuing responsibility for the patient during the study period of 24 months. The CGA is person-centered and unique for each patient, but is based on the core elements such as socio-demographic background, social network, health and medical history, medications, functional status, cognitive status, nutritional status, somatic status and psychosocial status including depression, providing a comprehensive assessment tailored for each person. Structured questionnaires and validated measures will be used.