The Reforça’t project reduces readmissions by 40% and improves the physical recovery and autonomy of frail people

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% in chronically frail patients with cardiorespiratory pathology during the first 30 days after discharge. The clinical trial, conducted with nearly 200 participants, also shows significant improvements in functionality, emotional well-being and adherence to prescribed treatments.

The six-month study was carried out as a randomized controlled clinical trial with a sample of 178 people aged 65 years or older: 90 integrated in the Reforça’t program and 88 in the usual care (control group). In the Reforça’t group there were 8 readmissions, while 13 were recorded in the control group. These data show a 40% reduction in readmissions among the 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 -physical recovery and autonomy to continue with daily activities- by 71%, have increased therapeutic adherence by 26%, that is, patients have followed the prescribed treatment more continuously and correctly, thanks to the monitoring and accompaniment 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 this demonstrates the positive impact of the model on the quality of life of frail people.

It should be remembered that cardiorespiratory diseases are one of the pathologies that lead to the most readmissions in the 30 days following discharge. This fact can accelerate the functional deterioration of the person, increase the risk of institutionalization and generate overload in the caregivers. In addition, the progressive aging of the population, the prevalence of chronic diseases and age-related frailty 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 frailty care.

This innovative program is based on five key areas: an interdisciplinary professional team, telemonitoring, therapeutic conciliation, home physiotherapy and social and health education.

The team is made up of different professionals: nurses, nursing assistants, physiotherapists, social workers and pharmacists, who coordinate with each other to ensure comprehensive care tailored to the needs of each individual. Telemonitoring is articulated through Better Care’s BC Home® platform, which allows remote symptom monitoring and the collection of experience and outcome data reported by the users themselves (PROMs and PREMs). This tool facilitates more proactive care and allows early detection of possible decompensation.

The program also includes a complete review by the pharmacist in coordination with the primary care physician of the prescribed treatment(therapeutic conciliation), home rehabilitation exercises adapted to each user, and a 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 d’Innovació Social i Sanitària (HiSS), within the second call “Community alternatives to institutionalization” and has proven to be an effective model of integrated care and continuity of care.

For more information: Communication and Image Unit of the CSMS – comunicacio@salutms.cat

Head of Unit – Maria Sistachs – 93 769 02 01 – Ext. 2236 – 619 78 13 73 – msistachs@salutms.cat

Communication Technician – Raquel Hernández – 93 769 02 01 – Ext. 2235 – 653 73 16 09 – vcarofrias@salutms.cat