The aim of this qualitative study was to explore the process of care provided by a community-based geriatric assessment and management team (the elderly resource team or ERT) through a critical incident approach. Cases were discussed both with the ERT alone and in combined discussions with referring primary health care teams, using an external facilitator. Data analysis was based on the critical incident technique and a grounded theory approach. Analysis of 11 cases generated a total of 496 events (a mean of 45 events per case). The numbers of positive events and negative events (areas of concern) were approximately equal (236 and 260, respectively). Certain important themes emerged from the data to describe how the elderly resource team managed their patients. Patients were often referred for covert reasons, such as negative emotions in informal and formal carers and inappropriate demands on them. Integrated multidisciplinary assessment by the team generated a realistic appraisal of the situation. With time, the key worker became a trusted professional, leading to recognition of the patient's poor psychological adjustment to their illness, and unexpected breakthroughs in their management, which previous carers had been unable to achieve. Reflection of these concepts back to informal and formal carers was considered to be supportive. Caring for such complex patients also produced negative emotions in the elderly resource team. Internal support for individuals in such teams can be offered via the concept of role transference. Through further analysis using a grounded theory approach, a conceptual model was developed to describe the process of care delivered. This model requires further testing in order to determine whether it is applicable to other multidisciplinary rehabilitation teams.