Conducted between July 2011 through September 2013 at Barnabas Health in Northern New Jersey. All patients age 65 and older who came into medical center’s emergency department or were admitted to the hospital were screened for dementia, frailty, and chronic conditions. Staff enrolled patients who met the criteria of frailty, dementia, and one or more chronic condition in the Transitions in Care program (n=640). After hospital discharge, case managers called patients and caregivers at one, three, six, and 12 months after discharge to ensure the patient saw his/her referring physician and received the necessary care. They also sent the care plan to the referring physician or facility. The Visiting Nurse Association of Central Jersey made home visits. CareOne at King James and HealthSouth Rehabilitation Hospital of Tinton Falls provided rehabilitation and therapy services. The hospital readmission rate at Monmouth Medical Center decreased by more than 39 percent (from 14.8% to 9%) among Transitions in Care program patients. 91 percent of Transitions in Care program patients saw their primary care provider within two weeks of hospital discharge . Patients and/or their caregivers were satisfied with the Transitions in Care program: 97 percent agreed or strongly agreed (52% strongly agreed and 45% agreed) that hospital staff considered their preferences and their caregiver’s preferences when planning care after leaving the hospital, 96 percent of patients and/or their caregivers agreed or strongly agreed (51% strongly agreed and 45% agreed) that they understood the purpose of taking their medications, and 92 percent agreed or strongly agreed (48% strongly agreed and 44% agreed) that they had a good understanding of things they were responsible for in managing their health.