Effectiveness of Nurse-based Care Coordination on Readmissions Among Primary Care Patients: a Stepped Wedge Cluster Randomized Trial

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