Post-Surgical Based Efforts to Reduce Preventable Readmissions and Optimize Length of Stay

Post-Surgical Based Efforts to Reduce Preventable Readmissions and Optimize Length of Stay

The investigators believe that hospital readmissions for intermediate- to high-complexity surgeries can be reduced by remote patient monitoring follow-up post-discharge, which involves daily touchpoints with a clinical nurse, vital sign evaluation and a symptom directed communication escalation process.

Inclusion Criteria:

• Adults (over 18 years of age)
• Undergoing one of the following inpatient elective surgery procedures: abdominal wall reconstruction, bariatrics, hepatectomy, pancreatectomy, aortic surgery, lower extremity bypass, esophagectomy and colectomy at Mayo Clinic Rochester.
• Must be willing to actively work with RPM nurses with vital sign capturing.

Exclusion Criteria:

• Have uncontrolled mental illness and/or drug or alcohol abuse
• Reside in a long-term care facility
• Are being actively followed by dialysis or transplant services
• Pregnant
• Are being actively treated for cancer, receiving chemo or radiation therapy during the remote monitoring
• Are identified as end-of-life by provider
• Have dementia, cognitive impairment, or physical condition that limits ability to use home remote monitoring equipment independently or interact with remote patient monitoring staff (unless a caregiver commits to assisting daily).