The subjects in this group receive complex interventions, including structured assessment, health education, goal empowerment, and care coordination supported by a health-social team.

The control group received usual discharge care and community resources that were made available to them as appropriate. A monthly social call was made to each client in the control group in order to exclude social effects. The contents of the social call, such as asking about entertainment and clients' hobbies, were set in the protocol.

An advanced practice nurse (APN) from a hospital discharge team visited them to familiarize him/herself with their condition and prepare a discharge plan. A face-to-face or telephone call handover between the APN and the project nurse case manager (NCM) was performed before the client was discharged. The past and current medical conditions, medical and nursing management, and follow-up appointments were discussed. After discharge home, the NCM, functioning as the leader of health-social care team, conducted the initial assessment in the first home visit to identify the client's health and social problems within one week of discharge. Community workers, supervised by both the nurse case manager and social worker, provided telephone follow-up and subsequent home visits to monitor the client's progress and provide support when necessary.

The goal for this program was to enable older adults to live with optimum quality of life in their own environment through receiving support from the collaboration of nurse case managers and social workers. Quality of life was measured by SF-12, which has been shown to be useful in Chinese elderly patients. The questionnaire has 12 items organized into eight categories (physical functioning, role limitation due to emotional and physical problems, mental health scale, general health, bodily pain, social functioning, and vitality), and has been validated in numerous studies.

Use Modified Barthel index to measure the subjects' ability to do basic activity of daily livings such as grooming, eating, and walking. The score is from 0-100, with higher scores representing better activity of daily living.