Reforça't: A Community, Social, and Healthcare Program for Patients With Cardiorespiratory Conditions Upon Hospital Discharge
For patients and families
In plain language
An automatic summary of structured registry data. It is an orientation aid, not a substitute for the official protocol or a physician assessment.
- What is being studied
- The protocol lists: Interdisciplinary Program for Post-Hospitalization / Hospital at home Management and Long-Term Outcomes in Older Adults with Chronic Cardiorespiratory Condition.
- Who it may be relevant to
- Registry conditions: Chronic Obstructive Lung Disease (COLD), Heart Failure. Basic parameters: from 65 years · All.
- What needs checking
- Age, condition and sex are only basic indicators. Prior treatment, laboratory values and other mandatory requirements appear in the eligibility criteria below.
- Where it takes place
- Spain
- Next step
- Save the trial, show it to the treating physician, and confirm current recruitment with the study center. Costs, documents and travel →
Unsure about the terms? Read our patient guide →
Official title
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
Overview
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.
Interventions
- Other Interdisciplinary Program for Post-Hospitalization / Hospital at home Management and Long-Term Outcomes in Older Adults with Chronic Cardiorespiratory Condition
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 pati
Primary outcome measures
- Reduction of the Readmission Rate in the Intervention Group [Time frame: 30 days after hospital discharge]
- Reduction of mortality, readmission and nursing home admission [Time frame: 3, 6, 9, and 12 months after hospital discharge]
Secondary outcome measures (12)
- Reduction in Frailty Index Score [Time frame: 30 days after hospital discharge]
- Reduction of the mortality rate [Time frame: 30 days after hospital discharge]
- Reduction in the number of inappropriate prescriptions [Time frame: 30 days after hospital discharge]
- Increase in pharmacotherapeutic adherence [Time frame: 30 days after hospital discharge]
- Reduction in functional deterioration [Time frame: 30 days after hospital discharge]
- Reduction in the risk of falls [Time frame: 30 days after hospital discharge]
- Increase in physical function [Time frame: 30 days after hospital discharge]
- Increase in the number of beneficiaries of social prescribing or community referrals [Time frame: 30 days after hospital discharge]
- Obtain positive patient satisfaction [Time frame: 30 days after hospital discharge]
- Reduction or delay in institutionalization in nursing homes among users [Time frame: 30 days after hospital discharge]
- Reduction in Zarit Score for caregiver burden [Time frame: 30 days after hospital discharge]
- Reduction in the risk of social isolation [Time frame: 30 days after hospital discharge]
Eligibility criteria
Inclusion criteria
- 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 criteria
- 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
Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.
Healthy volunteers: No
Study design
- Allocation
- Randomized
- Model
- Parallel assignment
- Masking
- Open label
- Primary purpose
- Prevention
Study locations
Spain · 1 center
- Hospital Comarcal de Calella - Corporació de Salut del Maresme i la Selva — Calella
Publications
- Aranda-Gallardo M, Morales-Asencio JM, Canca-Sanchez JC, Morales-Fernandez A, Enriquez de Luna-Rodriguez M, Moya-Suarez AB, Mora-Banderas AM, Perez-Jimenez C, Barrero-Sojo S. [Consequences of errors in the translation of questionnaires: Spanish version of Downton index]. Rev Calid Asist. 2015 Jul-Aug;30(4):195-202. doi: 10.1016/j.cali.2015.04.003. Epub 2015 Jun 9. Spanish. PMID 26068277
- Castellvi P, Forero CG, Codony M, Vilagut G, Brugulat P, Medina A, Gabilondo A, Mompart A, Colom J, Tresserras R, Ferrer M, Stewart-Brown S, Alonso J. The Spanish version of the Warwick-Edinburgh mental well-being scale (WEMWBS) is valid for use in the general population. Qual Life Res. 2014 Apr;23(3):857-68. doi: 10.1007/s11136-013-0513-7. Epub 2013 Sep 5. PMID 24005886
- Kocalevent RD, Berg L, Beutel ME, Hinz A, Zenger M, Harter M, Nater U, Brahler E. Social support in the general population: standardization of the Oslo social support scale (OSSS-3). BMC Psychol. 2018 Jul 17;6(1):31. doi: 10.1186/s40359-018-0249-9. PMID 30016997
- Zamora-Sanchez JJ, Zabaleta-Del-Olmo E, Gea-Caballero V, Julian-Rochina I, Perez-Tortajada G, Amblas-Novellas J. [Convergent and discriminative validity of the Frail-VIG index with the Braden scale in people cared for in home care]. Rev Esp Geriatr Gerontol. 2022 Mar-Apr;57(2):71-78. doi: 10.1016/j.regg.2021.12.003. Epub 2022 Mar 17. Spanish. PMID 35307198
- Charlson ME, Charlson RE, Peterson JC, Marinopoulos SS, Briggs WM, Hollenberg JP. The Charlson comorbidity index is adapted to predict costs of chronic disease in primary care patients. J Clin Epidemiol. 2008 Dec;61(12):1234-1240. doi: 10.1016/j.jclinepi.2008.01.006. Epub 2008 Jul 10. PMID 18619805
- Pinzon-Pulido S, Garrido Pena F, Reyes Alcazar V, Lima-Rodriguez JS, Raposo Triano MF, Martinez Domene M, Alonso Trujillo F. [Predictors of institutionalization of elderly persons in dependency situation in Andalusia]. Enferm Clin. 2016 Jan-Feb;26(1):23-30. doi: 10.1016/j.enfcli.2015.08.003. Epub 2015 Sep 9. Spanish. PMID 26363992
- Acosta-Benito MA, Martin-Lesende I. [Frailty in primary care: Diagnosis and multidisciplinary management]. Aten Primaria. 2022 Sep;54(9):102395. doi: 10.1016/j.aprim.2022.102395. Epub 2022 Jun 11. Spanish. PMID 35700618
- Bayona Huguet X, Limon Ramirez E, Cegri Lombardo F. [Proposals for home care of the XXI century]. Aten Primaria. 2018 May;50(5):264-266. doi: 10.1016/j.aprim.2017.11.003. Epub 2018 Feb 9. No abstract available. Spanish. PMID 29433757
Identifiers
NCT: NCT06897410 · R't