Aim: Integrated Multi-disciplinary Proactive Identification and Navigation Team (IMPRINT) is a novel model of care that targets community dwelling patients with high care home care packages who are at high risk for prolonged non-acute hospital admission. Using comprehensive geriatric assessment and navigation principles, IMPRINT links them to appropriate community services to provide support at home. Successful implementation of IMPRINT requires coordination among various healthcare groups: the IMPRINT team, general practitioners, the Aged Care Assessment Team, and various non-government services. If effective, IMPRINT could reduce prolonged hospital length of stay. Evaluation of IMPRINT will ensure that it meets the needs of patients and remains sustainable. Methods: This study incorporates process and outcome evaluation methods, and relational coordination theory to evaluate and enhance coordination amongst the healthcare groups involved in IMPRINT. Data is collected from surveys, focus groups, and interviews with team members from each healthcare group at two time points approximately twelve months apart. Results: Early findings from the first time point suggest that coordination between groups could be improved through more timely exchanges of critical information and a better understanding of each other’s role. Developing interventions to address these gaps provide opportunity for improvement. In the next phase, a follow-up round of surveys, focus groups, and interviews will assess changes after these interventions had been implemented. Conclusion: The study findings can be used to develop and evaluate solutions to support the implementation of IMPRINT and similar initiatives.