Impact of a care plan after hospital discharge on the lives of patients who need special care

Impact of implementing a Transitional Care pPan in patients with complex needs

Status

Active, not recruiting

Phases

Unknown

Study type

Interventional

Source

REBEC

Registry ID

RBR-8ytv6qy

Enrollment

120

Registered

2026-02-05

Start date

2024-03-01

Completion date

Unknown

Last updated

2026-03-02

For informational purposes only — not medical advice. Sourced from public registries and may not reflect the latest updates. Terms

Conditions

Patient Readmission

Interventions

This is a randomized controlled clinical trial with two parallel arms and a single-blind design, which will include a total of one hundred and twenty participants, equally distributed between the inte

Eligibility

Age

18 Years to No maximum

Inclusion criteria

Inclusion criteria: Adult patients (age equal to or greater than 18 years); both sexes; admitted to wards, intensive care units, or the Emergency Department of Hospital São Paulo with complex needs; who are scheduled for hospital discharge and for whom the responsible physician or nurse has requested an evaluation by the transition of care team

Exclusion criteria

Exclusion criteria: Previously included patients who are unable to understand the provided guidance; without a telephone; or who refuse to sign the Free and Informed Consent Form

Design outcomes

Primary

Measure	Time frame
To assess the incidence of unplanned readmission and death within the first 30 days after hospital discharge. The occurrence of these outcomes will be measured through telephone interviews conducted by trained nurses	—

Secondary

Measure	Time frame
It is expected to identify associations between clinical and care-related outcomes in the post-discharge period, including time to hospital readmission or death, primary cause of readmission, number of Emergency Department visits, level of activation for health self-management, patient satisfaction with the discharge process, and caregiver burden during the first 30 days after hospital discharge. These outcomes will be assessed through structured telephone follow-up and the application of validated instruments, including CONECT-6, the LACE score, the Patient Activation Measure (PAM), the Care Transitions Measure (CTM), and the Zarit Scale. Time (in days) to readmission or death, the absolute frequency of readmissions and emergency department visits, the percentage distribution of causes of readmission, as well as variations in instrument scores will be observed, considering means, standard deviations, and proportions, in order to determine whether the expected outcomes were achieved	—

Measure

Time frame

It is expected to identify associations between clinical and care-related outcomes in the post-discharge period, including time to hospital readmission or death, primary cause of readmission, number of Emergency Department visits, level of activation for health self-management, patient satisfaction with the discharge process, and caregiver burden during the first 30 days after hospital discharge. These outcomes will be assessed through structured telephone follow-up and the application of validated instruments, including CONECT-6, the LACE score, the Patient Activation Measure (PAM), the Care Transitions Measure (CTM), and the Zarit Scale. Time (in days) to readmission or death, the absolute frequency of readmissions and emergency department visits, the percentage distribution of causes of readmission, as well as variations in instrument scores will be observed, considering means, standard deviations, and proportions, in order to determine whether the expected outcomes were achieved

—

Countries

Brazil

Contacts

Public ContactAndréa da Costa

Universidade Federal de São Paulo - Unifesp

afcosta@unifesp.br+55-11-55764430

Outcome results

None listed

Source: REBEC (via WHO ICTRP) · Data processed: Mar 14, 2026