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.
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.
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
Parallel
Interdisciplinary Program for Post-Hospitalization / Hospital at home Management and Long-Term Outcomes in Older Adults with Chronic Cardiorespiratory Condition
Other interventionIntervention Phase 1: Feasibility Assessment Duration: January 7, 2025 - January 11, 2025 Participants: 10-15 patients Description: All involved services will be available to address and resolve potential issues. The objective is to assess the feasibility of the program, ensuring that the intervention can be implemented as planned and identifying any practical or logistical challenges. Phases 2 \& 3: Comprehensive Intervention Duration: January 12, 2025 - June 30, 2025 Participants: 200 patients Description: Full-scale implementation of the intervention. Includes interdisciplinary care, home follow-ups, therapeutic optimization, functional rehabilitation, health education, and psychosocial support. Phase 4: Long-Term Follow-Up Duration: April 7, 2025 - June 30, 2026 Participants: 200 patients Description: Follow-up assessments at 3, 6, 9, and 12 months post-intervention. Evaluates hospital readmissi
Reduction of the Readmission Rate in the Intervention Group
The investigators aim for the intervention to result in a 20% reduction of the readmission rate among users included in the experimental group
Reduction of mortality, readmission and nursing home admission
Reduction in Frailty Index Score
Reduction of the mortality rate
Reduction in the number of inappropriate prescriptions
Increase in pharmacotherapeutic adherence
The investigators will conduct the spanish version of the Adherence to Refills and Medications Scale (ARMS-e). Per this scale, high scores indicate low therapeutic adherence. Subjects are classified into high adherence (scores from 0 to 16), intermediate adherence (scores from 17 to 32), and low adherence (scores from 33 to 48). \- Expected experimental range values: 12 - 48
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Corporació de Salut del Maresme i la Selva
Lead sponsor
Consorci Sanitari de Terrassa
Collaborator
