Reforat A Community-Based Program to Improve Outcomes for Patients 65 and Older with Chronic Heart and Lung Conditions After Hospital Discharge

What this Trial Is About

Researchers are evaluating an interdisciplinary, community-based program called Reforat designed to reduce 30-day hospital readmissions and improve functional outcomes in patients aged 65 or older with chronic heart, lung, or mixed conditions after hospital discharge. The study aims to see if Reforat can lower readmission rates to 25% compared to standard care and improve medication adherence, quality of life, and survival. Patients will be compared between those receiving Reforat and those under usual care to assess health outcomes and cost-effectiveness. The intervention includes a full-scale program with interdisciplinary care, home follow-ups, therapeutic optimization, functional rehabilitation, health education, and psychosocial support. The trial also includes a feasibility phase and long-term follow-up. The intervention group receives presential follow-up by a multidisciplinary team, while the control group receives standard hospital-at-home care. Follow-up assessments occur at 3, 6, 9, and 12 months after discharge to monitor hospital readmissions, survival, nursing home admissions, and overall well-being. Participants will undergo assessments before and after the intervention, with a post-discharge evaluation at 30 days and continued monitoring up to 12 months. Researchers will collect data on readmissions, mortality, functional decline, medication adherence, risk of falls, social isolation, emotional well-being, and caregiver burden. Patient satisfaction and smoking cessation rates are also measured. This comprehensive evaluation aims to determine the programs impact on health outcomes and quality of life in older adults with chronic cardiorespiratory conditions.

Reforça't: A Community, Social, and Healthcare Program for Patients With Cardiorespiratory Conditions Upon Hospital Discharge