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.
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.
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
Corporació de Salut del Maresme i la Selva
Lead sponsor
Consorci Sanitari de Terrassa
Collaborator