Community care program for older adults with heart or lung disease after hospital discharge
Tests a community care program for older adults with heart failure or lung disease.
Plain-language title generated from the registry record
Registry title: Reforça't: A Community, Social, and Healthcare Program for Patients With Cardiorespiratory Conditions Upon Hospital Discharge
Key facts
- Where
- Calella, SpainSee the site
Where in Spain
- Hospital Comarcal de Calella - Corporació de Salut del Maresme i la SelvaCalella, SpainTaking people
Questions to ask the study team
- How often do I need to come in, and for how long each time?
- Are travel costs paid?
- Can I keep my own doctor?
- What happens if I want to stop?
Trial details
- Who runs it
- Corporació de Salut del Maresme i la Selva
- Trial code
- NCT06897410
- Record updated
- 30 May 2025
- Original description
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.Read full original descriptionShow less
Reforça't: A Randomized Community Clinical Trial With a Social and Healthcare Approach to Improve Functional Outcomes in Patients With Chronic Cardiac, Respiratory, or Mixed Conditions After Hospital Discharge
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.
Inclusion: 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: Users on the waiting list for organ transplantation; 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 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.