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

NCT06897410 | Recruiting DMC

• 1 other identifier: R't
• Study Type: interventional
• Target: 200
• Locations: 1 country
• Sites: 1

Brief Summary

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.

Conditions

Chronic Obstructive Lung Disease (COLD); Heart Failure

Keywords

Patient Readmission; COLD; Heart Failure; Frail elderly; Multidisciplinary care team

Outcome Measures

Primary Outcomes (2)

• 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

  30 days after hospital discharge

• Reduction of mortality, readmission and nursing home admission

  3, 6, 9, and 12 months after hospital discharge

Secondary Outcomes (14)

• Reduction in Frailty Index Score

  30 days after hospital discharge

• Reduction of the mortality rate

  30 days after hospital discharge

• Reduction in the number of inappropriate prescriptions

  30 days after hospital discharge

• Increase in pharmacotherapeutic adherence

  30 days after hospital discharge

• Reduction in functional deterioration

  30 days after hospital discharge

Study Arms (2)

Control Group

NO INTERVENTION

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

Intervention Group

EXPERIMENTAL

Presential Follow-up by a multidisciplinary team

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

Interventions

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

Intervention 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

Intervention Group

Eligibility Criteria

• Age: 65 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Older Adult (65+)

You may qualify if:

• 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

You may not qualify if:

• 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

Sponsors & Collaborators

• Corporació de Salut del Maresme i la Selva: lead
• Consorci Sanitari de Terrassa: collaborator

Study Sites (1)

Hospital Comarcal de Calella - Corporació de Salut del Maresme i la Selva

Calella, Barcelona, 08370, Spain

RECRUITING

Related Publications (24)

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MeSH Terms

Conditions

Pulmonary Disease, Chronic Obstructive; Heart Failure

Interventions

Aging

Condition Hierarchy (Ancestors)

Lung Diseases, Obstructive; Lung Diseases; Respiratory Tract Diseases; Chronic Disease; Disease Attributes; Pathologic Processes; Pathological Conditions, Signs and Symptoms; Heart Diseases; Cardiovascular Diseases

Intervention Hierarchy (Ancestors)

Growth and Development; Physiological Phenomena

Central Study Contacts

Griselda Manzano Monfort

CONTACT

+34620215477; gmanzano@salutms.cat

Noelia Quirant Arellano

CONTACT

+34695803416; nquirant@salutms.cat

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: NONE
• Purpose: PREVENTION
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Head of Hospital At Home Unit at Corporació de Salut del Maresme i la Selva (CSMS). Postdoctoral researcher at Digital Health Research Group (IDIBGI-CSMS)

Model Details: Randomized Intervention Study, control vs intervention group

Study Record Dates

• First Submitted: March 6, 2025
• First Posted: March 26, 2025
• Study Start: January 13, 2025
• Primary Completion (Estimated): June 30, 2026
• Study Completion (Estimated): June 30, 2026
• Last Updated: May 30, 2025

Record last verified: 2025-05

Data Sharing

• IPD Sharing: Will not share

Locations

ES (1)