This project will address the transitional care needs of 6,600 recently hospitalized frail elderly patients over 70 years old coping with multiple chronic and acute morbidities during 60 day episodes of care in Central New Jersey. The project’s three-tiered approach is designed to improve integration and information exchange during care transitions as follows: 1) Consulting with and training partners will strengthen transitional communications; 2) The Navigation Program will support patient transitions to the home, and 3) A comprehensive patient registry will improve and streamline electronic communications among partners.