Too often vulnerable older adults are left to fend for themselves when it comes to transitioning from the hospital to the next appropriate care setting. Stories abound of people being shipped back and forth from the hospital to temporary care to their homes and back to the hospital again when it all goes wrong. In California, approximately one in five or 81,000 Medicare beneficiaries every year end up re-hospitalized within 30 days of discharge for a medical condition that led to the original hospitalization. This figure increases to 2.5 million Medicare beneficiaries nationally, at a cost of nearly $17 billion a year.