Physicians who practice in the nursing home often must decide whether to hospitalize a patient with an acute illness or provide on-site treatment. Most medical problems--including urinary tract infection, pneumonia, venous thromboembolism, and exacerbations of congestive heart failure--can be successfully managed in the nursing home. An aggressive primary care approach can improve the quality of care for vulnerable older patients, reduce the need for hospitalizations, and make nursing home practice more efficient and satisfying. Most dying patients can also receive the bulk of their medical and palliative care in the nursing home.