Studies in the County of Stockholm reveal a malfunctioning care system for elderly persons with one or more diseases in conjunction with immobility and reduced strength. These multi-impaired elderly consume a substantial proportion of care and rehabilitation services. They would need a health co-ordinator to monitor the entire care process, dealing with all aspects of care, and whose sphere of responsibility is not unduly restricted. The communication of information from inpatient care to the primary care setting is highly problematic. Therefore it is proposed that the transfer of multi-impaired elderly individuals from inpatient care to outpatient primary care be a carefully monitored process. In addition, outside of the hospital an "elderly team" that would be composed of doctors, district nurses, rehabilitation personnel and care assistants is proposed. This team should have a geographically well-defined area of responsibility, in which they would provide care in the homes of these multi-impaired elderly.