Given the expected growth of older adults coping with complex chronic conditions, rapidly rising health care costs and, there is an urgent need to promote older adults access to high quality, cost*2deffective and efficient services.The Transitional Care Model (TCM) emphasizes identification of patients health goals, coordination and continuity of care throughout acute episodes of illness, development of a rationale, streamlined plan of care to prevent future hospitalizations and reduce health care costs, and preparation of the patient and family caregivers to implement this care plan all accomplished with the active engagement of patients and their family caregivers and in collaboration with the patients physicians and other health team members.