 The study is a stepped wedge randomized cluster study. Intervention: The transition care program, involving a dedicated advanced practice nurse, will include: 1 during the patients stay in hospital: an individualized needs-based comprehensive discharge plan and a transitional care record ; the notification of the primary care physician about inpatient care and hospital discharge; 2 the day of the discharge: specific explanations about the organization of home care provided by the transition care nurse to the patient; 3 during 4 weeks after discharge: monitoring patients and caregivers regularly through home visits andor telephone contact, 