The purpose of the PA4LE program is to prevent EMS calls, ED visits and hospital admissions from avoidable causes and decrease the use of high-risk medications among elders at the SLH. We are modeling the current study intervention in part after the Coleman Care Transitions Model, which is a patient and family-centered care transitions program from hospital to community. The components of the model will be translated into use for ED/Hospital to ALC transitions to avoid EMS calls, ED visits and hospital admissions/readmissions. To identify avoidable causes for admissions, we used the study by Ouslander et al. that determined frequency, causes and costs of potentially avoidable hospitalizations among nursing home residents. A maximum of 50 participants will be enrolled in the study per the inclusion and exclusion criteria.