Programs, generally staffed by an interdisciplinary team comprising a geriatrician, a nurse, a social worker and a pharmacist, that evaluate 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.

Programs that develop plans for the evaluation, treatment and/or care of individuals who, because of age, illness, disability or other difficulties, need assistance in planning and arranging for services; which assess the individual's needs; coordinate the delivery of needed services; ensure that services are obtained in accordance with the case plan; and follow up and monitor progress to ensure that services are having a beneficial impact on the individual. Case management is a collaborative process characterized by communication, advocacy and resource management to promote high quality, cost-effective interventions and outcomes.