Community program to support patients with heart and lung conditions after hospital discharge

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

Not applicable Interventional Corporació de Salut del Maresme i la Selva · NCT06897410

This study is testing a community program called Reforça't to see if it helps older patients with heart and lung conditions stay healthy and avoid going back to the hospital after they leave.

Quick facts

PhaseNot applicable
Study typeInterventional
Enrollment200 (estimated)
Ages65 Years and up
SexAll
SponsorCorporació de Salut del Maresme i la Selva Academic / other
Locations1 site (Calella, Barcelona)
Trial IDNCT06897410 on ClinicalTrials.gov

What this trial studies

This clinical trial aims to evaluate the effectiveness of the Reforça't program, an interdisciplinary, community-based intervention designed for patients aged 65 and older with chronic cardiorespiratory conditions. The program seeks to reduce 30-day hospital readmissions and improve functional outcomes by providing comprehensive care following hospital discharge. Participants will be randomly assigned to either the Reforça't program or standard care, with assessments conducted before and after the intervention to measure health outcomes, medication adherence, and quality of life. The study will compare the two groups to determine the program's impact on readmission rates and overall patient well-being.

Who should consider this trial

Good fit: Ideal candidates are individuals aged 65 or older who have been hospitalized for cardiac or respiratory issues and reside within the health coverage area of the participating hospital.

Not a fit: Patients who are institutionalized in nursing homes or those already enrolled in home care programs may not benefit from this intervention.

Why it matters

Potential benefit: If successful, this program could significantly reduce hospital readmissions and enhance the quality of life for elderly patients with chronic heart and lung conditions.

How similar studies have performed: Other studies have shown promise with community-based interventions for similar patient populations, suggesting potential for success in this approach.

Eligibility criteria

Show full inclusion / exclusion 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

Where this trial is running

Calella, Barcelona

Study contacts

How to participate

  1. Review the eligibility criteria above with your treating physician.
  2. Visit the official trial page on ClinicalTrials.gov for the most current contact information and recruitment status.
  3. Contact the listed study coordinator or principal investigator to request pre-screening. Pre-screening is free and never obligates you to enroll.
Conditions Chronic Obstructive Lung DiseaseHeart FailurePatient ReadmissionCOLDFrail elderlyMultidisciplinary care team
Last reviewed 2026-06-13 by the Find a Trial editorial team. Information on this page is for educational purposes and is not medical advice. Always consult qualified healthcare professionals about clinical trial participation.