Background: Older adults experience health deconditioning during hospitalization. There are many facets of care impacting on older adults' health characteristics and their self confidence in managing their health. The aim of this follow-up study is to examine the long term effect of comprehensive discharge planning and nursing in-home follow-up for older adults (over 65 year old) incorporating physiotherapy exercise strategies on health characteristics. No published studies were located that had examined the impact of a comprehensive discharge program on the functional status and psychosocial among older frail adults at 12 months post-discharge. Design and methodology: Rehabilitation in Older People (RIO program) is a randomised controlled trial which evaluates the intervention of a comprehensive discharge program, exercise program incorporating nursing follow up. Participants of the RIO study were randomly allocated into usual care control group and an intervention group. The intervention group received a comprehensive training from an advanced practice gerontic nurse (APGN) and exercise strategies by physiotherapists. The APGN visited the participants in their home 48 hours post discharge, followed by telephone follow-up at 4, 8, 12 and 24 weeks. This study followed-up this cohort at 12 month via telephone interviews to evaluate their functional ability, quality of life, psychosocial characteristics and the levels of self-efficacy. The General Self-efficacy Scale (GSE) was used to measure their self-efficacy. Results: There is no difference between the demographic and health characteristics between the control and intervention group. There are significant difference in their functional ability, psychosocial health, measured by the tools mentioned above at 4 weeks (p < 0.05), 12 weeks (p < 0.05), and 24 weeks (p < 0.05), but not at 52 weeks. The possible reason could be due to lack of telephone follow up. Moreover, the levels of self-efficacy in this sample have been found to correlate with the functional ability and psychosocial at 12 months after discharge from an acute hospital.