This trial will evaluate the effectiveness of nurse-based care coordination and nurse-based remote patient monitoring on hospital readmissions among primary care patients.

Inclusion Criteria:

• Discharged from the hospital in the past 7 days
• LACE+ score of 59 or greater and at least two chronic conditions
• Index hospitalization with discharge directly to community dwelling home (home, assisted living)
• English speaking
• 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 assigned to the panel of a Mayo Clinic Medical Doctor/Nurse Practitioner/Physician Assistant
• Access to and ability to communicate via telephone (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
• 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 the patient's care coordination
• Patients with active tuberculosis (TB)
• Violent patient flag noted in Epic (for adult medical care coordination)
• Patient declines home visit (for adult medical care coordination)
• Patient is already enrolled in remote patient monitoring or the care transitions program