This is a pragmatic effectiveness-implementation trial to evaluate a hospital-to-home transitional care intervention compared to usual care for older adults with multiple chronic conditions and depression. The aim of this study is to determine the effects and costs of a hospital-to-home support program for older adults with depression and multiple chronic conditions. The overall goal is to improve health outcomes in older adults with depression and other health problems, by improving patients’ self-management ability, supporting families and caregivers, and building capacity for primary care and other health and non-health providers to collaborate in delivering home and community services to the target population. Community forums will be held in each participating area to engage stakeholders, learn about existing transitional care initiatives that can be built upon, and establish local Community Advisory Boards as well as a study-wide Steering Committee and Patient and Caregiver Advisory Group. Through these groups, patients, caregivers, providers and researchers will work side-by-side to design and test the program in diverse settings to inform rapid scale-up across Ontario. CO-PIs are Dr. Maureen Markle-Reid and Dr. Carrie McAiney.