No enrollment

The overall aim of this study is to create a trans-disciplinary chronic disease continuity of care model with health information technology, utilizing mobile devices such as tablets, iPads and smartphones.

This study aims to explore if a trans-disciplinary chronic disease continuity of care model with integrated technology (mobile devices such as tablets, iPads and smartphones) to standard practice (patient-centered, coordinated care model without the integration of technology) will results in a reduction in 30-day readmission rate in adult patients.

Inclusion Criteria:

• Adult patients on a 43 bed medical surgical unit
• Adult patients on 44 bed geriatric unit

Exclusion Criteria:

• Adult patients admitted and not diagnosed with chronic disease
• Patients who are transferred between Intervention and non-Intervention unit
• Patients who refuse
• Patients with delirium, dementia and altered mental status
• Patients who cannot read and write in any language
• Patients in the intervention group who cannot use mobile technology