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 chances of hospitalization. PaJR has completed Phase 1, comparing hospitalization rates between monitored patients and controls. Phase 2 is an ongoing regional trial monitoring over 130 patients. Preliminary results show the control group has approximately 3 times higher unplanned admission rates. PaJR aims to detect health issues earlier to reduce avoidable hospitalizations through low-cost monitoring and support.