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This innovative model is based on five key elements: a team made up of different professionals, telemonitoring, therapeutic reconciliation, home physiotherapy and social support to provide integrated, close and proactive care.
The Corporació de Salut del Maresme i la Selva (CSMS) has presented the results of Reforça't, a pioneering and innovative program that, thanks to a new model of care, has managed to reduce hospital readmissions by 40% for frail chronic patients with cardiorespiratory pathology during the first 30 days after discharge. The clinical trial, conducted with about 200 participants, also shows significant improvements in functionality, emotional well-being and follow-up to prescribed treatments.
The six-month study was carried out as a randomized controlled clinical trial with a sample of 178 people aged 65 and over: 90 integrated into the Reforça't program and 88 with regular care (control group). In the Reforça't group, there have been 8 readmissions, while 13 have been registered in the control group. These data show a 40% reduction in readmissions among people participating in the program.
The preliminary results are convincing: in addition to the reduction in the number of readmissions, patients in the program have improved their functionality by 71% —physical recovery and autonomy to continue with daily activities— have increased therapeutic adherence by 26%, that is, patients have followed the prescribed treatment more continuously and correctly, thanks to the follow-up and support of the professional team and have experienced an improvement in emotional well-being of 72% compared to patients who have not been part of the program. All of this demonstrates the positive impact of the model on the quality of life of fragile people.
It should be remembered that cardiorespiratory diseases are one of the pathologies that cause the most readmissions to people who suffer from them in the 30 days after discharge. This fact can accelerate the functional deterioration of the person, increase the risk of institutionalization and create burden on the people who care for them. In addition, the progressive aging of the population, the prevalence of chronic diseases and frailty associated with age are transforming the health and social landscape.
Faced with this challenge, Reforça't offers an integrated, close and interdisciplinary response that addresses both clinical and social needs. The project aims to consolidate itself as a reference model in community health and in frailty care. This innovative program is based on five key areas: an interdisciplinary professional team, telemonitorization, therapeutic reconciliation, home physiotherapy and social and health education.
The team is made up of different professionals: nurses, nursing assistants, physiotherapy, social work and pharmacy, who coordinate with each other to ensure comprehensive care adapted to the needs of each person. Telemonitorization is articulated through the platform BC Home® by Better Care, which makes it possible to monitor symptoms remotely and collect experience data and results reported by the users themselves (PROMs and PreMS). This tool provides more proactive care and makes it possible to detect possible decompensations early.
In addition, the program also includes a complete review by the pharmacist with the coordination of the primary care medical professional of the prescribed treatment (therapeutic conciliation), home rehabilitation exercises adapted to each user, and social assessment and emotional support aimed at improving the experience of both patients and caregivers. This initiative has been developed within the framework of the Transforma Program and the Hub of Social and Health Innovation (HiSS), as part of the second call “Community Alternatives to Institutionalization” and has been demonstrated to be an effective model of integrated care and continuity of care.
