Inclusion Criteria:  Veterans discharged from the Indianapolis VA medical center (VAMC) for an medical/surgical diagnosis (excludes substance use disorder-related admissions; excludes planned admissions) within the prior week Age 70 years Not enrolled in home-based primary care (HBPC) Not enrolled in hospice Not in dialysis Primary care visit within VA in the prior 2 years Not residing in nursing home, skilled nursing facility, or CLC. Living >20 miles but <60 miles from the Indianapolis VAMC facility CAN score 95th percentile for mortality or missing CAN score Discharged from the hospital alive  Exclusion Criteria:  Patients who have been randomized to the control arm after their index hospitalization who become readmitted to the hospital may not be re-randomized. By definition, GRACE patients are not eligible for TeleGRACE due to the drive distance >20 miles from the Indianapolis VAMC Enrolled in home-based primary care (HBPC) Enrolled in hospice Dialysis (hemodialysis or peritoneal dialysis) Residing in nursing home, skilled nursing facility, or CLC. Living <20 miles or 60 miles from the Indianapolis VAMC facility