Guided Care: Integrating High Tech and High Touch

The purpose of the study is to evaluate the effect of a Guided Care nurse on the quality of the health and well-being of the frail elderly. A specially trained registered nurse will work closely with 1-3 primary care physicians to provide the most complex older patients (and their unpaid caregivers) with health care that is comprehensive, coordinated, patient-centered, and proactive. The study will evaluate the effects of Guided Care on: * older persons' physical and mental health, health services utilization, quality of care, self-efficacy, and satisfaction with care; * older persons' unpaid caregivers' burden; and * primary care physicians' satisfaction with their care of chronically ill patients.