Navigation for Elderly People With Multiple Morbidity After Hospital Discharge.

NCT07546006 | Not Yet Recruiting DMC

• 2 other identifiers: 2026-004595858326.9.0000.5327
• Study Type: interventional
• Target: 148
• Locations: 1 country
• Sites: 1

Brief Summary

This research aims to create and test a tracking (navigation) model to assist in providing care guidance to elderly people (60 years or older) who have two or more chronic diseases at the same time (multimorbidity) immediately after being discharged from the hospital.

Conditions

Multimorbidity

Keywords

Aged; Patient Navigation.; Multimorbidity; Comprehensive Health Care; Geriatric Nursing

Outcome Measures

Primary Outcomes (1)

• Adherence to self-care

  Assessed by the Brazilian version of the Self-Care of Chronic Illness Inventory

  6 months

Study Arms (2)

intervention

EXPERIMENTAL

submitted to the navigation protocol

Behavioral: Navigation for elderly people after hospital discharge.

Control

PLACEBO COMPARATOR

The participant will receive the usual care, without additional supervision.

Other: Routine care.

Interventions

Navigation for elderly people after hospital discharge. BEHAVIORAL

Patients in the intervention group will be followed for six months through monthly teleconsultations by the doctoral researcher and other nurses with experience in elderly health, as well as nursing students who will be trained and supervised by the researcher to provide standardized care in order to avoid bias.

intervention

Routine care. OTHER

Routine care.

Control

Eligibility Criteria

• Age: 60 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• Elderly individuals aged 60 or older;
• With confirmed multimorbidity documented in their medical records;
• Hospitalized in the SUS (Unified Health System) clinical units (5th North, 6th North, and 7th North), regardless of specialty;
• Who will be discharged home;
• Have telephone access and have a primary caregiver responsible for assisting with communication, in cases where the elderly person is unable to respond for themselves.

You may not qualify if:

• Elderly people hospitalized in restricted access clinical units (6th south), and those with private insurance or paying out-of-pocket (4th south);
• Those transferred to another hospital service or to other institutions;
• Patients who are already receiving or will receive navigation care or other safe discharge follow-up care;
• Patients in palliative care.

Sponsors & Collaborators

• Hospital de Clinicas de Porto Alegre: lead

Study Sites (1)

Hospital de Clínicas de Porto Alegre

Porto Alegre, Rio Grande do Sul, 90410-000, Brazil

Location

Study Officials

• Idiane Rosset, pdh

  Federal University of Rio Grande do Sul

  PRINCIPAL INVESTIGATOR

Central Study Contacts

Emily da Silva Eberhardt, Nurse researcher

CONTACT

+5551998921355; enfemilyeberhardt@gmail.com

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: SINGLE
• Who Masked: PARTICIPANT
• Purpose: SUPPORTIVE CARE
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Model Details: Patients in the intervention group will be followed for six months through monthly teleconsultations by the doctoral researcher and other nurses with experience in elderly health, as well as nursing students who will be trained and supervised by the researcher to provide standardized care in order to avoid bias.

Study Record Dates

• First Submitted: April 15, 2026
• First Posted: April 22, 2026
• Study Start (Estimated): June 1, 2026
• Primary Completion (Estimated): July 30, 2027
• Study Completion (Estimated): March 30, 2028
• Last Updated: April 22, 2026

Record last verified: 2026-04

Data Sharing

• IPD Sharing: Will not share

Locations

BR (1)