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The purpose of this study was to evaluate the impact of a primary home care intervention program on patient outcomes after selected patients were discharged from a short-stay hospital. Random assignment of 249 frail, elderly patients was made to a group provided with physician-led primary home care, and home assistance service on a 24-hour basis, or to a control group given standard care. At randomization, patients were considerably disabled, had a mean age of 80.5 years, and had a high likelihood of long-stay hospital care. Medical and functional data were essentially the same at baseline for both groups. At 6-months follow-up, significant improvement in instrumental activities of daily living (P = 0.04) and outdoor walking (P = 0.03), and medical condition was found in the primary care intervention group compared with the controls and less utilization of long-stay hospital facilities was displayed in the team patients (P < 0.001) than in the controls. A selection of elderly, dependent patients can be cared for in their homes after short-stay hospital discharge and benefit from this primary home care intervention program in terms of improved medical and functional outcomes and less long-stay hospitalization.