Inclusion Criteria:

• Discharged from hospital in the past 7 days or observation status.
• Age ≥ 18 years.
• LACE+ score ≥ 59 and at least two chronic conditions.
• Index hospitalization with discharge directly to community dwelling (home, assisted living).
• English speaking.
• Discharge to home (residential dwelling) or assisted living, as appropriate and determined by the study coordinator.
• Normal cognitive function. Mild dementia or mild cognitive impairment is allowed if a caregiver is able to work with the care coordinator and patient during program enrollment.
• Mayo Clinic or Mayo Clinic Health System provider managing the patient’s care (e.g. primary care).  Patient is paneled to a Mayo Clinic MD/NP/PA.
• Access to and ability to communicate via telephone and/or video (either patient or caregiver).

Exclusion Criteria:

• Psychiatric hospital admission.
• Patients with a serious and persistent mental health disorder or severe treatment interfering behavior that require a higher level of service than is available at the patient’s clinic.
• Untreated active substance or alcohol abuse.
• Dementia or moderate to severe cognitive impairment.
• Discharged to one of the following:
  • Rehabilitation unit;
  • Skilled nursing facility;
  • Assisted living memory unit;
  • Group home;
  • Transitional care unit.
• Pregnancy.
• Active treatment for cancer.
• Receiving dialysis or transplant services.
• Life expectancy < 6 months or enrolled in hospice or palliative care programs.
• Patient is unwilling to sign a Release of Information (ROI) – (ROI allows those providing care, internal and external to be actively involved in patient’s care coordination).
• Patients with active tuberculosis (TB).
• Violent patient flag noted in Epic.
• Patient is already enrolled in Remote Patient Monitoring or the Care Transitions Program (CTP), Palliative Care Homebound Program (PCHP), or Primary Care House Calls Program (PCHP), Advanced Care at Home (ACH) Program (NW WI).
• Recent or active COVID patient (i.e., discharged from COVID admission, active COVID event)
• Religious Sisterhood living at Mayo Clinic Hospital - St. Mary’s Campus or Assisi Heights (Rochester only).
• Permanently living in a long-term care facility or a memory unit of an assisted living facility.
• Chronic pain syndrome if chronic pain is the only diagnosis and no chronic medical condition exists.