Background: The aging of the population and the consequences resulting from multimorbidity processes and chronic diseases are increasingly a current reality in society. Its association with processes of fragility and loss of functionality encourages the search for intervention models address sustainable responses, meeting people’s self-care needs from a perspective of functionality and promoting autonomy. Objective: To describe a nursing practice model that allows the identification of Specialist Nurse in Rehabilitation intervention and his role in act to respond to the phenomena of frailty and loss of functionality by the elderly. Methodology: This is a descriptive and reflective study, using the references of rehabilitation nursing in Portugal, and basing the reflection on Orem’s theory of Self-Care. Results: The model considered focus on the existence of concepts that underpin nursing practice, such as commitment, responsibility, recognition and excellence. Conclusion: This model adapts rehabilitation interventions for elderly people with some degree of functional disability in a systematic, structured and high-quality way.