Impact of Pharmacist-led Care Navigation Mediated by Digital Health Tools on Hospital Readmissions

NCT07789353 | Not Yet Recruiting

• 2 other identifiers: 2026-035499456126.3.0000.5327
• Study Type: interventional
• Target: 3,220
• Locations: 1 country
• Sites: 1

Brief Summary

Hospitalizations for Primary Care-Sensitive Conditions (PCSCs) are potentially avoidable hospital admissions that may be prevented when Primary Health Care provides effective and timely care through prevention, early diagnosis, appropriate management of chronic conditions, and control of acute episodes. This study proposes an open-label, pragmatic, cluster-randomized clinical trial to evaluate the effectiveness of continuous telecare, supported by digital health tools, in the post-discharge follow-up of patients hospitalized for PCSCs. The main outcome will be the occurrence of non-elective hospital readmissions and urgent or emergency care visits within 180 days after discharge, compared with usual care. The intervention will include pharmacist-led teleconsultations, a communication channel through a messaging app, and the development of an individualized care plan. Participants in the control group will receive the usual care provided by the healthcare network.

Conditions

Ambulatory Care Sensitive Conditions

Keywords

Transitional Care; Ambulatory Care Sensitive Conditions; Remote Patient Monitoring; Patient Readmission; Patient Discharge

Outcome Measures

Primary Outcomes (1)

• Occurrence of non-elective hospital readmissions and visits to urgent and emergency care services within 180 days after hospital discharge

  Occurrence of non-elective hospital readmissions and visits to urgent and emergency care services within 180 days after hospital discharge, assessed through patient/caregiver reports during follow-up visits and electronic medical records.

  From enrollment until 180 days after hospital discharge

Secondary Outcomes (3)

• Proportion of participants who died within 180 days after hospital discharge

  From enrollment until 180 days after hospital discharge

• Proportion of participants who fully or predominantly completed the actions outlined in the individualized care plan

  From enrollment until 180 days after hospital discharge

• Satisfaction with continuous pharmacist-led care

  From enrollment until 180 days after hospital discharge

Study Arms (2)

Pharmacist-led teleconsultations

ACTIVE COMPARATOR

Continuous pharmacist-led care program supported by digital health tools, which will include: three pharmacist teleconsultations, with the first consultation within 15 days after hospital discharge, the second within 30 days, and the third within 90 days; an open communication channel through a messaging app; an individualized care plan; and referrals to Primary Health Care professionals, when necessary.

Behavioral: Pharmacist-led teleconsultations

Usual care

NO INTERVENTION

Usual care provided by the hospital and Primary Health Care services, without implementation of the structured pharmacist-led care program supported by digital health tools.

Interventions

Pharmacist-led teleconsultations BEHAVIORAL

Continuous pharmacist-led care program supported by digital health tools, which will include: three pharmacist teleconsultations, with the first consultation within 15 days after hospital discharge, the second within 30 days, and the third within 90 days; an open communication channel through a messaging app; an individualized care plan; and referrals to other Primary Health Care professionals, when necessary.

Also known as: Remote Consultation, Remote Patient Monitoring, Community Pharmacy Services, Pharmaceutical Services, Online, Pharmaceutical Services, Medication Therapy Management

Pharmacist-led teleconsultations

Eligibility Criteria

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

You may qualify if:

• Individuals aged 18 years or older;
• Residing in the municipality of Porto Alegre;
• Hospitalized at Hospital de Clínicas de Porto Alegre for selected Primary Care-Sensitive Conditions (PCSCs): respiratory diseases (such as asthma, chronic obstructive pulmonary disease, and tuberculosis), cardiovascular diseases (such as arterial hypertension, angina, and heart failure), cerebrovascular diseases (such as stroke), and metabolic diseases (such as diabetes mellitus).

You may not qualify if:

• Individuals who are unable to be contacted by telephone;
• Individuals with language or cognitive barriers that cannot be overcome with the assistance of a caregiver or legal representative;
• Individuals participating in another clinical trial that conflicts with the present study.

Sponsors & Collaborators

• Hospital de Clinicas de Porto Alegre: lead
• Institute of Artificial Intelligence in Health: collaborator

Study Sites (1)

Hospital de Clínicas de Porto Alegre

Porto Alegre, Brazil

Location

MeSH Terms

Conditions

Ambulatory Care Sensitive Conditions

Interventions

Remote Consultation; Remote Patient Monitoring; Community Pharmacy Services; Pharmaceutical Services, Online; Pharmaceutical Services; Medication Therapy Management

Condition Hierarchy (Ancestors)

Disease Attributes; Pathologic Processes; Pathological Conditions, Signs and Symptoms

Intervention Hierarchy (Ancestors)

Referral and Consultation; Professional Practice; Organization and Administration; Health Services Administration; Telemedicine; Delivery of Health Care; Patient Care Management; Community Health Services; Health Services; Health Care Facilities Workforce and Services; Medicare Part D; Insurance, Pharmaceutical Services; Insurance, Health; Insurance; Financing, Organized; Economics; Health Care Economics and Organizations; Medicare

Study Officials

• Diego Gnatta, PhD

  Federal University of Rio Grande do Sul

  STUDY CHAIR

Central Study Contacts

Bianca V Bianchini, PhD

CONTACT

+55 51 31914125; bianca@noharm.ai

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: NONE
• Purpose: OTHER
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: August 24, 2026
• First Posted: August 27, 2026
• Study Start: August 1, 2026
• Primary Completion (Estimated): August 1, 2027
• Study Completion (Estimated): January 1, 2029
• Last Updated: August 27, 2026

Record last verified: 2026-08

Locations

BR (1)