The Patient Journey Record System (PaJR) uses lay care guides to remotely monitor patients with chronic illnesses through daily phone calls. The calls analyze patients' health and social situations to predict health risks and the need for hospitalization. PaJR has completed Phase 1, which found lower hospitalization rates among monitored patients compared to controls. Phase 2 is ongoing in two sites and continues to recruit more patients and controls. Preliminary results again show lower admission rates for monitored patients. The system aims to detect health issues earlier through closer monitoring to reduce avoidable hospitalizations and shift care to the community.