Home Telemonitoring in Patients at High Risk for Readmission


About this study

This study will evaluate the efficacy of home telemonitoring as an intervention to decrease hospital readmissions in patients at high risk for readmission. The overall readmission rate for high-risk MCF hospital patients is approximately 20%. Currently a system is in place to identify and score all MCF patients for their risk of readmission. This score is based on multiple variables including but not limited to: co-morbid conditions, patient's health literacy, whether they are a Medicare/Medicaid patient, their in-home social support, and whether they have had prior hospital admissions within the previous year. The literature shows that home telemonitoring of patients has had mixed results for effectiveness at preventing hospitalizations and emergency department visits. Many of these reports have restricted studies to patients with specific diseases or general characteristics; some have shown improved results while others have not. No study has examined patients who are high risk for readmission to determine if home telemonitoring for 30 days post-discharge reduces the risk for 30-day readmission.

Participation eligibility

Participant eligibility includes age, gender, type and stage of disease, and previous treatments or health concerns. Guidelines differ from study to study, and identify who can or cannot participate. There is no guarantee that every individual who qualifies and wants to participate in a trial will be enrolled. Contact the study team to discuss study eligibility and potential participation.

Inclusion Criteria:

  1. Readmission risk score of 11 or higher
  2. May be from any service in the hospital
  3. Patient discharged home or
  4. Patient discharged to one of the five most commonly used skilled nursing/rehabilitation facilities by MCF (Brooks Rehab, Cypress Village, Life Care Center of Jacksonville, Avante Village at Jacksonville Beach, River Garden)
  5. If the patient has a planned readmission within the next 30 days

Exclusion Criteria:

  1. international
  2. under age 18
  3. discharged to hospice
  4. discharged to a sub-acute care hospital
  5. transferred to an acute care hospital or
  6. transferred to a skilled facility other than the five listed above.

Participating Mayo Clinic locations

Study statuses change often. Please contact the study team for the most up-to-date information regarding possible participation.

Mayo Clinic Location Status Contact

Scottsdale/Phoenix, Ariz.

Mayo Clinic principal investigator

Bryan Hull, M.D.

Closed for enrollment

Contact information:

Cindy Azevedo M.S.

(480) 342-2816


Jacksonville, Fla.

Mayo Clinic principal investigator

Nancy Dawson, M.D.

Closed for enrollment

Contact information:

Clinical Studies Unit

(904) 953-2255

More information


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