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NOT YET RECRUITING
NCT07789353
NA

Impact of Pharmacist-led Care Navigation Mediated by Digital Health Tools on Hospital Readmissions

Sponsor: Hospital de Clinicas de Porto Alegre

View on ClinicalTrials.gov

Summary

Hospitalizations for Primary Care-Sensitive Conditions (PCSCs) are potentially avoidable hospital admissions that may be prevented when Primary Health Care provides effective and timely care through prevention, early diagnosis, appropriate management of chronic conditions, and control of acute episodes. This study proposes an open-label, pragmatic, cluster-randomized clinical trial to evaluate the effectiveness of continuous telecare, supported by digital health tools, in the post-discharge follow-up of patients hospitalized for PCSCs. The main outcome will be the occurrence of non-elective hospital readmissions and urgent or emergency care visits within 180 days after discharge, compared with usual care. The intervention will include pharmacist-led teleconsultations, a communication channel through a messaging app, and the development of an individualized care plan. Participants in the control group will receive the usual care provided by the healthcare network.

Official title: Impact of Pharmacist-led Care Navigation Mediated by Digital Health Tools on Hospital Readmissions After Discharge: a Randomized Clinical Trial.

Key Details

Gender

All

Age Range

18 Years - Any

Study Type

INTERVENTIONAL

Enrollment

3220

Start Date

2026-08

Completion Date

2029-01-01

Last Updated

2026-08-27

Healthy Volunteers

No

Interventions

BEHAVIORAL

Pharmacist-led teleconsultations

Continuous pharmacist-led care program supported by digital health tools, which will include: three pharmacist teleconsultations, with the first consultation within 15 days after hospital discharge, the second within 30 days, and the third within 90 days; an open communication channel through a messaging app; an individualized care plan; and referrals to other Primary Health Care professionals, when necessary.

Locations (1)

Hospital de Clínicas de Porto Alegre

Porto Alegre, Brazil