本文描述運用整合性照護模式，包含周全性老人評估、跨科整合團隊及個案管理制度，協助一位因衰弱症引發跌倒而住院之長者與其成功返家的護理經驗。住院期間為2016年1月17日至2016年1月23日，以周全性老人評估為工具，透過會談、觀察、跨科整合及醫療團隊討論並收集資料，找出導致個案衰弱的內、外在因素，確立護理問題，包含營養狀況少於身體所需、潛在危險性跌倒、自我照顧功能缺失、無望感等。住院期間照會老年醫學科，結合跨科高齡照護團隊，邀請個案、家屬參與團隊會議，擬訂可執行之返家照護計畫與目標，結合在地長照中心、非營利組織與居家雲端照護技術，確保安全無障礙的居家環境；返家後持續個案管理服務(2016年1月23日至2016年7月25日)，以電訪及返診時複評周全性老人評估以追蹤、評值照護成效。透過此模式，有效改善個案問題，促使其能攝取適當營養、持續復健運動、保持動態的生活型態，達成生活功能恢復，延緩衰弱與其它併發症產生，回歸自理、自立、有尊嚴的生活。

This article describes the use of an integrated care mode that includes comprehensive geriatric assessment (CGA), a multidisciplinary team, and case management to assist in the case of an elderly patient who was hospitalized due to a fall caused by frailty and then returned home successfully. The period of hospital care was from January 17, 2016, to January 23, 2016, and was based on CGA as a tool for gathering information through interviews, observation, interdisciplinary team meetings, and discussions with members of the medical team to identify internal and external factors that lead to frailty and establish associated care-related problems. These included inadequate nutritional status, potential risk of falling, missing self-care functions, and feelings of hopelessness. During the hospital stay, a cross-disciplinary care team was formed, and the patient and family members were invited to participate in a meeting to jointly develop a homecare plan for the implementation of care goals. In addition to regional long-term care centers, nonprofit organizations and home cloud care technology can ensure a safe and caring home environment. After the patient returned home, case management services continued to track and assess the effectiveness of care through telephone calls and visits to re-evaluate CGA. The model was found capable of effectively improving the patient's care, prompting the patient to take appropriate nutrition, perform rehabilitation exercises, maintain a dynamic lifestyle, and resume normal life activities for self-care, self-reliance, and a dignified life.