Reforça't: A Community, Social, and Healthcare Program for Patients With Cardiorespiratory Conditions Upon Hospital Discharge

Reduction in Frailty Index Score

Time frame: 30 days after hospital discharge

Reduction of the mortality rate

Time frame: 30 days after hospital discharge

Reduction in the number of inappropriate prescriptions

Time frame: 30 days after hospital discharge

Increase in pharmacotherapeutic adherence

The investigators will conduct the spanish version of the Adherence to Refills and Medications Scale (ARMS-e). Per this scale, high scores indicate low therapeutic adherence. Subjects are classified into high adherence (scores from 0 to 16), intermediate adherence (scores from 17 to 32), and low adherence (scores from 33 to 48). \- Expected experimental range values: 12 - 48

Time frame: 30 days after hospital discharge

Reduction in functional deterioration

The investigators will measure Barthel and Lawton scores to determine functional activity. Barthel index indicates the ability to perform daily tasks autonomously. Higher Barthel index equals higher degree of autonomy. Values range from 0 to 100. Scores lower than 20 indicate total dependence, between 20 and 35 equal severe dependence, between 50 and 55 indicate moderate dependence, between 60 and 90 indicate light dependent, and higher than 95 indicate autonomy. Lawton and Brody scores measure the degree of autonomy in the performance of instrumental activities of daily living. Values range from 0 to 8, with higher score indicating higher autonomy.

Time frame: 30 days after hospital discharge

Reduction in the risk of falls

The investigators will assess the Downton score. This measure is expected to decrease in the intervention group. Values range from 0 to 11, where higher score equals higher risk. Starting at 3, the values are considered to indicate relevant risk of fall.

Time frame: 30 days after hospital discharge

Increase in physical function

The investigators will conduct Short Physical Performance Battery (SPPB) and assess Daniels score, to determine subjects' physical function. * SPPB values range from 0 to 12. Higher score equals higher physical function (less frailty). Values lower than 10 indicate clinically relevant frailty and risk of falls * Daniel's score values range from 0 to 5. Higher values indicate higher strength for the evaluated muscle. Each value indicates; i) 0-absence of contraction, ii) 1- contraction without movement, iii) 2- movement with gravity eliminated iv) 3-full range of motion against gravity, v) 4-full range of motion against moderate resistance, vi) 5-full range of motion against maximum resistance

Time frame: 30 days after hospital discharge

Increase in the number of beneficiaries of social prescribing or community referrals

Time frame: 30 days after hospital discharge

Obtain positive patient satisfaction

The investigators will administer ad hoc patient satisfaction surveys. Results will be numerical, from 0 (min) to 10 (max). Average above 7 will be considered a success, although results greater than 5 will be deemed satisfactory.

Time frame: 30 days after hospital discharge

Reduction or delay in institutionalization in nursing homes among users

Time frame: 30 days after hospital discharge

Reduction in Zarit Score for caregiver burden

The investigators will conduct Zarit Burden Interviews (ZBI) on caregivers for patients included in the study. Specifically, the short ZBI-7 will be assessed. It consists of 7 items, each item scoring from 1 to 5. Per this score, the higher the score equals a higher caregiver burden. Thus, a reduction in the Zarit Score for caregivers included in the study is expected. The obtained values per caregiver range from 7 to 35, and a total score of 17 or higher is considered excessive burden.

Time frame: 30 days after hospital discharge

Reduction in the risk of social isolation

The investigators will determine OSSS-3 score for patients included in the study. Higher scores determine higher perception of social support. Scores between 3 and 8 equal low social support, between 9 and 11 intermediate social support, and higher scores equal high social support. The patients included in the study are expected to range between 3 and 14.

Time frame: 30 days after hospital discharge

Increase in emotional well-being

The investigators will conduct the short Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS) to measure subject emotional well-being. Higher scores indicate better emotional wellbeing. A score lower than 26 is considered to relate to emotional discomfort. The patients included are expected to range between 7 and 35 in score (35 is the maximum score for this short version).

Time frame: 30 days after hospital discharge

Increase in the smoking cessation rate

Time frame: 30 days after hospital discharge