The ambition of this study is to raise the quality of care for old and chronically ill patients by establishing a sustainable, systematic prevention and integrated care model for users of home care services.

In this cluster randomized study the intervention will be carried through in five municipalities and three general hospitals. The home care units in every municipality will be randomized to either intervention og control units.

The primary objective of this study is to develop a functional and integrated care model between primary and secondary health care that will meet the needs both in the city and in smaller rural areas.

The secondary objective of this study is to reduce the need of care at primary and secondary level through a a systematic and integrated follow-up by home care nurses and general practitioners to:

• Enable these patients to manage their health needs more efficiently and independently
• Achieve better collaboration within primary care
• Achieve better collaboration between primary- and secondary health care professionals
• Achieve increased satisfaction and confidence with the health care services by the users and their relatives both for included patients and other patients receiving home care services.
• Promote health and prevent unnecessary decline in health
• Strengthen the patients' ability to manage their daily activities.

Inclusion Criteria:

• Person 70 years or above being discharged from the general hospital
• Will receive home care services within four weeks after being discharges from the hospital.

Exclusion Criteria:

• Do not agree or are not able to agree to participate
• Is already involved in other research studies affecting the home care services.