Navigation for Elderly People With Multiple Morbidity Aft... | NCT07546006

Studies
Navigation for Elderly People With Multiple Morbidity After Hospital Discharge.

NCT07546006

Sponsor

Hospital de Clinicas de Porto Alegre

Status

Not yet recruiting

Last Update Posted

Apr 22, 2026Actual

Enrollment

148Estimated

Phase

Not Applicable

Conditions

Multimorbidity

Interventions

Navigation for elderly people after hospital discharge.
Routine care.

Countries

Brazil

Protocol Section

Identification Module Status Module Sponsor/Collaborators Module Oversight Module Description Module Conditions Module Design Module Arms/Interventions Module Outcomes Module Eligibility Module Contacts/Locations Module References Module IPD Sharing Statement Module

Results Section

Participant Flow Module Baseline Characteristics Module Outcome Measures Module Adverse Events Module More Info Module

Annotation Section

Annotation Module

Document Section

Large Document Module

Derived Section

Miscellaneous Info Module Condition Browse Module Intervention Browse Module

Protocol Section

Identification Module

NCT ID

Results Section

No data available

No data is available for this block.

Annotation Section

No data available

No data is available for this block.

Document Section

No data available

No data is available for this block.

Derived Section

Miscellaneous Info Module

Version Holder

ID	Type	Description	Link
95858326.9.0000.5327	Other Identifier	CAAE

Status Module

Record Verification Date

Apr 2026

Overall Recruitment Status or Expanded Access Status

Not yet recruiting

Last Known Status

Not provided

Delayed Posting

Not provided

Why Stopped

Not provided

Expanded Access Info

Start Date

Jun 1, 2026Estimated

Primary Completion Date

Jul 30, 2027Estimated

Completion Date

Mar 30, 2028Estimated

First Submitted Date

Apr 15, 2026

First Submission Date that Met QC Criteria

Apr 15, 2026

First Posted Date

Apr 22, 2026Actual

Results Waived

Not provided

Results First Submitted Date

Not provided

Results First Submitted that Met QC Criteria

Not provided

Results First Posted Date

Not provided

Certification/Extension (aka Delayed Results) First Submitted Date

Not provided

Certification/Extension First Submitted that Passed QC Review

Not provided

Certification/Extension First Posted Date

Not provided

Last Update Submitted Date

Apr 15, 2026

Last Update Posted Date

Apr 22, 2026Actual

Oversight Module

Has Data Monitoring Committee (DMC)

Yes

Is FDA Regulated Drug

Is FDA Regulated Device

Is Unapproved Device

Not provided

Pediatric Postmarket Surveillance of a Device Product

Not provided

Product Exported from US

Not provided

FDAAA801 Violation

Not provided

Description Module

Brief Summary

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.

Detailed Description

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.

Design Module

Study Type

Interventional

Number of References to an Expanded Access Study

Not provided

Expanded Access Types

Not provided

Patient Registry

Not provided

Target Follow-Up Duration

Not provided

Phases

Not Applicable

Interventional Study Design

Allocation

Biospecimen

No data available

No data is available for this block.

Enrollment

148Estimated

Arms/Interventions Module

Arm Groups

Label	Type	Description	Intervention Names
intervention	Experimental	submitted to the navigation protocol	Behavioral: Navigation for elderly people after hospital discharge.
Control	Placebo Comparator	The participant will receive the usual care, without additional supervision.	Other: Routine care.

Interventions

Name	Type	Description	Arm Group Labels	Other Names
Navigation for elderly people after hospital discharge.	Behavioral	Patients in the intervention group will be followed for six months through monthly teleconsultations by the doctoral researcher and other nurses with experience in elderly health, as well as nursing students who will be trained and supervised by the researcher to provide standardized care in order to avoid bias.

Outcomes Module

Primary Outcomes

Measure	Description	Time Frame
Adherence to self-care	Assessed by the Brazilian version of the Self-Care of Chronic Illness Inventory	6 months

Secondary Outcomes

Not provided

Other Outcomes

Not provided

Eligibility Module

Eligibility Criteria

Inclusion Criteria:

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.

Exclusion Criteria:

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.

Accepts Healthy Volunteers

Sex

All

Sex/Gender Based

Not provided

Sex/Gender Description

Not provided

Minimum Age

60 Years

Maximum Age

Not provided

Standard Ages

AdultOlder Adult

Study Population

Not provided

Sampling Method

Not provided

Contacts/Locations Module

Central Contacts

Name	Role	Phone	Extension	Email
Emily da Silva Eberhardt, Nurse researcher	Contact	+5551998921355		enfemilyeberhardt@gmail.com

Overall Officials

Name	Affiliation	Role
Idiane Rosset, pdh	Federal University of Rio Grande do Sul	Principal Investigator

Locations

Facility	Status	City	State	ZIP	Country	Contacts
Hospital de Clínicas de Porto Alegre		Porto Alegre	Rio Grande do Sul	90410-000	Brazil

IPD Sharing Statement Module

Plan to Share IPD

Description

Not provided

Types

Not provided

Time Frame

Not provided

Access Criteria

Not provided

URL

Not provided

Intervention Model Description

Patients in the intervention group will be followed for six months through monthly teleconsultations by the doctoral researcher and other nurses with experience in elderly health, as well as nursing students who will be trained and supervised by the researcher to provide standardized care in order to avoid bias.