This paper aims to update knowledge about the structure of a complete line of care for the elderly. It is a model based on early identification of risks for frailty of users. Once identified the risk, priority is early rehabilitation in order to reduce the impact of chronic conditions on functionality. Assuming it is appropriate to prioritize the process of care, according to the functional losses that occur over the years, seven points of attention are established. The model is hierarchical by functional capacity, but polyarchical in practice, since from the first three levels it is possible to follow any other point of attention. This model is advantageous for the elderly, which improves the quality of life; for the family, whixh will have their relative activated and participatory, and for health operators, which will avoid repeated and costly hospitalizations.
Elderly; Disease Prevention; Episode of Care; Quality of Life; Health Care Line; Functional Capacity
