She is over 62, in rather poor health, obese, fallen a few times recently and asked for a walker with a chair to deal with getting tired when walking around. They are going to assess her home for safety and whether she needs to be cared for in a home.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2768550/
Who is suggesting the transitional care team?
It is a useful process for those with complex medical issues who are in danger of poor handoffs from home to facility or hospital to home.