The Transitional Care Model is designed to prevent health complications and rehospitalizations of chronically ill, elderly hospital patients by providing them with comprehensive discharge planning and home follow-up, coordinated by a master’s-level “Transitional Care Nurse” who is trained in the care of people with chronic conditions. At the time of hospitalization, the Nurse: (i) conducts a comprehensive assessment of the patient’s health status, health behaviors, level of social support, and goals; (ii) develops an individualized plan of care consistent with evidence-based guidelines, in collaboration with the patient and her doctors; and (iii) conducts daily patient visits, focused on optimizing patient health at discharge.