During a single illness episode, the sickest, frailest older patients are often treated in multiple distinct sites, including the emergency room, the intensive care unit, a general medical floor, and a skilled nursing facility. Such frequent transfers involve changes in physician, changes in nursing care, the rewriting of orders, and physical dislocation, all of which can adversely affect outcomes. This system, although efficient, increases the chance of medical errors, promotes delirium, and undermines the doctor-patient relationship. Partial solutions include a team approach to care, an electronic medical record, and substitution of home for hospital care. A more comprehensive solution is to create a geriatric hospital for treatment of the most common medical and surgical problems and for provision of rehabilitative or skilled nursing care. Designing new institutions for geriatric care will require new legislation and a new set of regulations but should be considered for the oldest and frailest patients.