Constance M. and Byron F. Dyer Fellowship from Houston Methodist Academic Institute, for the development and implementation of an ambulatory remote patient monitoring model aimed at reducing 30- and 90-day hospital readmissions and emergency department revisits among high-risk chronic disease patients. The project builds upon the White Plains Hospital Cares RPM model—integrating remote monitoring, telepharmacy, and community paramedicine—to support transitions from inpatient to outpatient care, and to establish discharge and follow-up protocols that enable early detection of clinical deterioration through home-based technology.