Successful chronic care ideally involves patient engagement, but little is known about chronically ill older adults' ability to self-manage their health. This study examines activation among hypertensive patients older than 65 years. Almost 60% of participants scored in the bottom half of the activation scale; only 8% scored at the highest level. Higher activation was associated with higher self-ratings of health, health literacy, and receipt of patient-centered care, shorter lengths of stay, and lower depression and hearing impairment levels. Effective self-management support for chronically ill elders will likely require varied strategies and may need to address depression, health literacy, and/or hearing impairments.