The alpine space is challenging for mobile care organizations as rural homes of patients are often characterized through long way distances or might be sometimes even isolated due to weather conditions. Real-time monitoring features for supporting mobile care require the easy conduction of self-measurements on vital signs for patients. Therefore, a vital sign telemonitoring system got conceptualized, utilizing the potential of Information and Communication Technology (ICT). The aim of this work was to gather technical and user-related requirements for a patient-centered telemonitoring system. Therefore, a mixed approach was followed comprising a comprehensive technical review, a literature review and interviews with stakeholders. Suitable use cases were derived from the gathered technical and user-related requirements. The results yielded to a concept for a seamless integrated, unobtrusive home monitoring system for elderly people with real-time data synchronization and communication features to support the mobile nurse organization, which got implemented and evaluated in the field. The concept overcomes known barriers of usability on telemonitoring systems like complex interaction which might lead to more efficiency and effectiveness in mobile nursing. The developed concept got further implemented as a prototype and validated within a 3-month test period.