This quality improvement project implemented medical house call as a component of transitional care management (TCM) and measured patient outcomes such as unplanned 30-day readmission rates and correlated predictors of readmission. As a secondary outcome, the project tracked and analyzed point-of- care concerns. Medicare beneficiaries 65 years and older who were discharged from skilled nursing facilities to home were offered a home visit by a nurse practitioner (NP). Older adults benefited from TCM medical house calls by a NP within 14 days after discharge by significant polypharmacy reduction and managed high readmission risk.