Navigation for Elderly People With Multiple Morbidity After Hospital Discharge.
试验速览
- 阶段
- 不适用
- 状态
- 尚未招募
- 入组人数
- 148
- 试验地点
- 1
- 主要终点
- Adherence to self-care
研究概览
简要总结
This research aims to create and test a tracking (navigation) model to assist in providing care guidance to elderly people (60 years or older) who have two or more chronic diseases at the same time (multimorbidity) immediately after being discharged from the hospital.
详细描述
A validated and tested navigation protocol applicable to the care of elderly individuals with multimorbidity after hospital discharge will be applied. Implementation of this protocol may demonstrate greater adherence to self-care, improved ability to navigate the healthcare system, and a lower readmission rate among participants. Thus, this research reinforces the strategic role of nursing in care coordination, strengthening evidence-based practices and contributing to health policies focused on healthy aging.
研究设计
- 研究类型
- Interventional
- 分配方式
- Randomized
- 干预模型
- Parallel
- 主要目的
- Supportive Care
- 盲法
- Single (Participant)
入排标准
- 年龄范围
- 60 Years 至 —（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •Elderly individuals aged 60 or older;
- •With confirmed multimorbidity documented in their medical records;
- •Hospitalized in the SUS (Unified Health System) clinical units (5th North, 6th North, and 7th North), regardless of specialty;
- •Who will be discharged home;
- •Have telephone access and have a primary caregiver responsible for assisting with communication, in cases where the elderly person is unable to respond for themselves.
排除标准
- •Elderly people hospitalized in restricted access clinical units (6th south), and those with private insurance or paying out-of-pocket (4th south);
- •Those transferred to another hospital service or to other institutions;
- •Patients who are already receiving or will receive navigation care or other safe discharge follow-up care;
- •Patients in palliative care.
研究组 & 干预措施
intervention
submitted to the navigation protocol
干预措施: Navigation for elderly people after hospital discharge. (Behavioral)
Control
The participant will receive the usual care, without additional supervision.
干预措施: Routine care. (Other)
结局指标
主要结局
Adherence to self-care
时间窗: 6 months
Assessed by the Brazilian version of the Self-Care of Chronic Illness Inventory
次要结局
未报告次要终点