 All questionnaires for measuring the outcome variables in this study have been demonstrated good validity and reliability. Nurse case managers and social workers will be trained by the research team members in order to provide consistent interventions from various professionals in the health-social care team and ensure the quality of the program. The nurse case managers will be employed with a criterion of experienced community nursing background. The process of home visits and telephone conversation will be recorded for review and evaluation. The research team members and health-social care team members will have meeting regularly to discuss the cases so as to ensure the practice is aligning with the protocols. This randomized controlled study will also stringently follow the Consolidated Standards of Reporting Trials CONSORT statement. 