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NCT Number: NCT07789353

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

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.

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Key information

Conditions

Ambulatory Care Sensitive Conditions Disease Attributes Pathologic Processes Pathological Conditions, Signs and Symptoms

Age range

18 year and older

Sex eligibility

All sexes

Study type

Interventional

Phase

Not applicable

Primary location

Hospital de Clínicas de Porto Alegre

Porto Alegre, Brazil

Who can participate

Healthy volunteers accepted: No

Only the study team can determine whether someone qualifies for participation.

Inclusion criteria

  • Individuals aged 18 years or older;
  • Residing in the municipality of Porto Alegre;
  • Hospitalized at Hospital de Clínicas de Porto Alegre for selected Primary Care-Sensitive Conditions (PCSCs): respiratory diseases (such as asthma, chronic obstructive pulmonary disease, and tuberculosis), cardiovascular diseases (such as arterial hypertension, angina, and heart failure), cerebrovascular diseases (such as stroke), and metabolic diseases (such as diabetes mellitus).

Exclusion criteria

  • Individuals who are unable to be contacted by telephone;
  • Individuals with language or cognitive barriers that cannot be overcome with the assistance of a caregiver or legal representative;
  • Individuals participating in another clinical trial that conflicts with the present study.

Treatment and study plan

Pharmacist-led teleconsultations

Behavioral

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.

Other names: Remote Consultation, Remote Patient Monitoring, Community Pharmacy Services, Pharmaceutical Services, Online, Pharmaceutical Services, Medication Therapy Management

Primary outcomes

  1. Occurrence of non-elective hospital readmissions and visits to urgent and emergency care services within 180 days after hospital discharge

    Time frame: From enrollment until 180 days after hospital discharge

    Occurrence of non-elective hospital readmissions and visits to urgent and emergency care services within 180 days after hospital discharge, assessed through patient/caregiver reports during follow-up visits and electronic medical records.

Secondary outcomes

  1. Proportion of participants who died within 180 days after hospital discharge

    Time frame: From enrollment until 180 days after hospital discharge

    Proportion of participants who died within 180 days after hospital discharge, assessed through caregiver reports and medical records.

  2. Proportion of participants who fully or predominantly completed the actions outlined in the individualized care plan

    Time frame: From enrollment until 180 days after hospital discharge

    Proportion of participants who fully or predominantly completed the actions outlined in the individualized care plan, as documented in pharmacist teleconsultations and medical records. An individualized care plan will be developed for each participant based on the Clinical Protocols and Therapeutic Guidelines of the Brazilian Ministry of Health and will include agreed-upon actions. Throughout the follow-up period, completion of the planned actions will be documented. Participants will be considered adherent to the care plan if there is documentation that they completed all planned actions or at least 75% of them within the defined period.

  3. Satisfaction with continuous pharmacist-led care

    Time frame: From enrollment until 180 days after hospital discharge

    Satisfaction with continuous pharmacist-led care will be assessed using the Net Promoter Score (NPS), based on the standard question: "On a scale from 0 to 10, how likely are you to recommend pharmacist-led telecare to a friend or family member?". Respondents will be classified as promoters (score 9-10), passives (score 7-8), or detractors (score 0-6). The NPS will be calculated as the difference between the percentage of promoters and the percentage of detractors, resulting in a score ranging from -100 to +100 (NPS = % Promoters - % Detractors).

Study contacts

Contact information is provided by the study sponsor or research team.

Bianca V Bianchini, PhD

CONTACT

[email protected]

+55 51 31914125

Sponsors and collaborators

Lead sponsor

Hospital de Clinicas de Porto Alegre

Other

Collaborators

  • Institute of Artificial Intelligence in Health

Registry information

Official study title

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

Important dates

Study start
2026
Primary completion
2027
Study completion
2029
First posted
Aug 27, 2026
Registry last updated
Aug 31, 2026

OpenTrials presents study information sourced from ClinicalTrials.gov. The official registry record should be consulted for the latest information.

View the official ClinicalTrials.gov record (opens in a new tab)

This listing is for discovery and informational purposes only. It is not medical advice, does not guarantee that a study is recruiting, and does not determine eligibility. Contact the study team and a qualified healthcare professional when considering participation.

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