Objective: In recent years a variety of system models for providing community based health care services to the elderly has been envisioned and implemented in the developed countries which meet the special care needs of different groups of elders. In Iran due to lack of these systems development, implementation and evaluation of these care system models from aspects of effectiveness and efficiency seems to be necessary.

Materials & Methods: In this study a model of social and health care system for community dwelling frail elders was implemented on 36 such elders for approximately six months and their respective expected outcomes were evaluated. The model has been developed in another study using a qualitative inquiry approach with named methodological triangulation (i.e. comprehensive literature review, panel of experts and ethnography on elders’ life styles and health practices). Implementation of Comprehensive Geriatric Assessment Tool, staff meetings for care planning, adopting an interdisciplinary approach with collaboration among all team members and case management rather than disease management were the most significant characters of this care delivery system.

Results: Investigation of Pretest scores and posttest score in two experimental and control group showed a statistical significance differences.

Conclusion: The preliminary results of employing this care system and examination of expected outcomes such as enhancing quality of life and hope in elders reflects the efficiency of this system, although further complementary studies and particularly cost benefit analysis are strongly recommended.