Inclusion Criteria:  Patient participants (N=402) will be included in the study if they:  Are aged 60+ Identify as African American or Latino/Hispanic (any race) Are being discharged from one of our three hospital partners to home with no planned readmissions Have access to a household telephone or cellphone Speak English or Spanish  Exclusion Criteria:  Patient participants will be excluded from the study if they:  Are younger than age 60 Identify as any race/ethnicity other than African American or Latino/Hispanic Are being discharged with a condition that has planned readmission (e.g. transplant patient, chemotherapy etc.) Are permanent residents of a skilled nursing facility, receiving hospice service, or are being discharged to a long-term care facility Have a comorbid substance use disorder Are actively suicidal or homicidal Have a comorbid psychotic disorder or organic mental disorder (e.g., dementia)