The objective of this RCTwas to examine the sustained effect of a 3-month comprehensive transitional care (discharge planning and home follow-up) intervention directed by advanced practice nurses (APNs) for elders hospitalized with heart failure on time to first readmission or death, total rehospitalizations, readmissions due to heart failure and comorbid conditions, quality of life, functional status, patient satisfaction, and medical costs. This study presents,on a spectrum of clinical and economic outcomes, the first multisite assessment of a transitional care intervention targeting the comprehensive set of serious health problems and risk factors common in elders throughout an acute episode of heart failure.