For frail, rural dwelling elders and their families, hospitalization represents a crisis of the most ominous nature. Not only must these older patients cope with acute illness problems, but they must do so in the context of health care cost containment. For elderly persons residing in rural areas such as those found in Pennsylvania, this crisis does not resolve when they exit the hospital, often prematurely, and return home to continue recuperating. Although numerous studies have shown that the post-discharge period is a pivotal one for older patients, conventional reimbursement strategies do not provide for and additional health care services so necessary for recovery. Consequently, readmissions to the hospital and adverse outcomes after discharge are the highest in persons who are elderly and frail impaired. The degree to which the influences of a rural environment add additional hardships in identifying and accessing needed post-discharged support services is not known. Clinical nurse specialist have demonstrated the ability to effectively meet the specific post-discharged support services is not know. Clinical nurse specialist have demonstrated the ability to effectively meet the specific post-discharge health care needs of high-risk hospital patients. In this experimental study, the CNS will be used to provide post-discharge care for frail, rural-dwelling elderly patients, along with their families and concerned others. An equivalent control group will not receive this specialist care. Utilization of health care resources, the patient s cognitive and functional status, and family or concerned other s general health and caregiving stress will be compared between the treatment and control groups at four different points in time. Results of longitudinal data collection are expected to show that the CNS intervention significantly improved the quality of care for frail, rural elders and their families.