Abstract: A patient monitoring system to automate remote care management and to reduce hospital readmissions for disease state management, patient health and wellness, medication adherence, and clinical care coordination; includes component for patient self-reporting and monitoring devices, component for patient/care team communications, component for care team time tracking and billing, component for creating, scoring, scheduling, assigning, and trialing questionnaires, component for work list, prioritizing and ranking of patients, and component for notification alerts to entire clinical care team: nurses, doctors, patient, caregivers, and patient advocates.

Abstract: A patient monitoring system to automate remote care management and to reduce hospital readmissions for disease state management, patient health and wellness, medication adherence, and clinical care coordination; includes component for patient self-reporting and monitoring devices, component for patient/care team communications, component for care team time tracking and billing, component for creating, scoring, scheduling, assigning, and trialing questionnaires, component for work list, prioritizing and ranking of patients, and component for notification alerts to entire clinical care team: nurses, doctors, patient, caregivers, and patient advocates.