Frail elderly would become disabled and increase the needs for medical care even after a minor stress. The European countries and the US have already developed different integrated post-acute care (PAC) models thirty years ago. Its importance is beyond words. We share our experiences of frailty home PAC in the Renai Branch, Taipei City Hospital in this article. An ideal frailty PAC relies on comprehensive geriatric assessment and intervention before discharging from the hospital, home-based physical therapy when return home, and arranging the transition to home-based medical care and long-term care after service. Our next step will be to find proper patient population, get physicians to involve, and let patients understand the importance of PAC.