The Transition Program at Monmouth Medical Center will serve people age 65 and older with dementia and multiple other chronic conditions a population at high risk for adverse health outcomes, hospital readmission, and mortality. This program consists of eight core components: 1) patient-identified goals and activities; 2) barrier and support resources identification; 3) patient and caregiver education; 4) prescription reconciliation and education; 5) multidisciplinary case conferencing; 6) development of a detailed, patient-specific My Care Plan 7) ‘receiving provider’ notification; and 8) follow-up care and home visits. Expected outcomes include decreased 30-day readmission rates, decreased Emergency Department visits, and cost-effectiveness.