Adopting a Health-social Partnership Program to Promote Health and Self-care Management Among Older Adults in the Community

On enrolment, the nurse case manager will perform the initial comprehensive assessment based on the Omaha domains of environment, psychosocial, physiological and health-related behavior. The nurse case manager will execute the intervention scheme of teaching, guidance \& counseling, treatments \& procedure, case management, and/or surveillance, with the mutual goal set with clients to promote health and self-efficacy. Home visits and telephone calls will be employed. The referral network to health and social service will be activated as appropriate.

Subjects in the control group will receive usual community service. in addition, a monthly social control call from trained community workers will be given to rule out the possible social effects of the intervention. These social calls will not be related the participants' health condition nor delivery of any health information.