Transitional Excellence through Coordinated Systems (TECS) is an evidence based project, modeled on Project RED (Re-Engineered Discharge) and the Transitional Care Model (TCM), within Our Lady of Lourdes Medical Center (OLLMC) in Camden, New Jersey. The purpose of TECS is to promote effective transitions in care for elderly populations with chronic health conditions and complex social issues.  Through the use of a coordinated system of community partners, patient/ care partner engagement, navigation from a Discharge Advocate RN, and post-hospital phone contact, the TECS project will improved quality of care, enhance patient satisfaction, reduce costs, and reduce hospital readmissions.