Thailand changes into aging society. Approximately ten million of Thai people have passed the age of 60, which is more than 10% of the population. Our declining birth rate and rising life expectancy are driving this change. More challenging problem is how our national health care system takes care of these senior citizens. Elderly population in Pak Kret District in Nonthaburi is accounting for 15.5% of overall population. In our responsible area, there are 23 people who are encountering difficulty in their daily basis. Thirty nine per cent of these elderly had moderate-to-severe disability even among ones with independent status. Working with Nonthaburi Municipality, the health care team of Panyanathaphikkhu Chonprathan Medical Center (PCMC) has a responsibility to screen the elderly performance and classify the disable patients to access in clinical management. One caregiver (CG) is assigned for 6 elderly in order to provide throughout comprehensive care. Care manager (CM) works with multidisciplinary care team in an individual weekly care plan. During this 1-year pilot project, older people get fundamental care service and rehabilitation program including nutrition and pharmacy counselling. Cooperated with family member, our team delivers treatment and restoration as well as maintain the functional ability that enables wellbeing for senior citizens.

1. 165/360 (45%) elderly in Pak Kret community are screened by Barthel Activities of Daily Living.
2. 23 older people with moderate-to-severe health condition are poor in functional activity enrolling in the long term care program.
3. 5/19 (26%) older people with moderate-to-severe score have a level up improvement after participating in 1-day program.
4. Elderly receive heartwarming care from their neighbors and youth health care volunteer.
5. This project is one of clinical tools helping dependent elderly to access in health equity.