Reforça't: A Community, Social, and Healthcare Program for Patients With Cardiorespiratory Conditions Upon Hospital Discharge (R't)

Corporació de Salut del Maresme i la Selva

Status: Enrolling

Conditions: Chronic Obstructive Lung Disease (COLD); Heart Failure

Treatments: Other: Interdisciplinary Program for Post-Hospitalization / Hospital at home Management and Long-Term Outcomes in Older Adults with Chronic Cardiorespiratory Condition

Study type: Interventional

Funder types: Other

Identifiers

NCT06897410

R't

Details and patient eligibility

About

The goal of this randomized clinical trial is to determine whether an interdisciplinary, community-based intervention can reduce 30-day hospital readmissions and improve functional outcomes in patients aged 65 or older with chronic cardiac, respiratory, or mixed conditions following hospital discharge.

The main questions it aims to answer are:

Can the Reforça't program reduce 30-day hospital readmission rates to 25% compared to standard care? Does participation in Reforça't improve functional outcomes, medication adherence, quality of life, and mortality rates in this patient population?

Researchers will compare patients enrolled in Reforça't (intervention group) with those receiving standard care (control group) to determine whether the program leads to lower readmission rates, improved health outcomes, and higher cost-effectiveness.

Participants will:

Undergo a pre- and post-intervention assessment (30 days post-discharge). Receive comprehensive, interdisciplinary care integrating medical, social, and rehabilitation services.

Be monitored for 12 months to assess readmissions, survival, nursing home admissions, and overall well-being.

Enrollment: 200 estimated patients

Sex: All

Ages: 65+ years old

Volunteers: No Healthy Volunteers

Inclusion criteria

• Users admitted to the Polivalent Observation Units, Internal Medicine, or Hospital at home.
• Individuals aged 65 years or older.
• Hospital admission due to decompensation of a cardiac, respiratory, or mixed condition.
• Place of residence within the health coverage area of Sant Jaume de Calella Hospital - Corporació de Salut del Maresme i la Selva.
• Willingness to participate in the study as gathered by the signing of an informed consent document

Exclusion criteria

• Users institutionalized in a nursing home
• Users already enrolled in home care programs
• Users in the Advanced Chronic Care Model program with a limited life prognosis
• Users on the waiting list for organ transplantation
• Users with language barriers
• Users with a GDS (Global Deterioration Scale) score of 5 or higher
• Users who have already been included in the Reforça't program

Trial design

Primary purpose: Prevention

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: None (Open label)

---

200 participants in 2 patient groups

Control Group

No Intervention group

Description:

Standard Follow-up under hospital at home regime in our institution

Intervention Group

Experimental group

Description:

Presential Follow-up by a multidisciplinary team

Treatment:

Other: Interdisciplinary Program for Post-Hospitalization / Hospital at home Management and Long-Term Outcomes in Older Adults with Chronic Cardiorespiratory Condition