Abstract
Following hospital discharge, millions of patients continue to recover outside formal healthcare organizations (HCOs) in designated transitional care periods (TCPs). Unplanned hospital readmissions of patients during TCPs adversely affects the quality and cost of care. In order to reduce the rates of unplanned hospital readmissions, we propose a real-time patient-centric system, built around applications, to assist discharged patients in remaining at home or in the workplace while being supported by care providers. Discrete-event system modeling techniques and supervisory control theory play fundamental roles in the system's design. Simulation results and analysis show that the proposed system can be effective in documenting a patient's condition and health-related behaviors. Most importantly, the system tackles the problem of unplanned hospital readmissions by supporting discharged patients at a lower cost via home/workplace monitoring without sacrificing the quality of care.