Program, generally staffed by an interdisciplinary team comprising a geriatrician, a nurse, a social worker and a pharmacist, that evaluates the functional ability, physical health, cognitive and mental health and socioenvironmental situation of older adults, particular those who are frail or chronically ill, to identify health-related problems, develop plans for treatment and follow-up, coordinate care, determine the need for long-term care, and ensure the optimal use of health care resources. Beneficial outcomes may include greater diagnostic accuracy, improved functional and mental status, reduced mortality, decreased use of nursing facilities and acute care hospitals and increased satisfaction with care.