MultimorbidityNAVIMNCT07546006
Navigation for Elderly People With Multiple Morbidity After Hospital Discharge.
A study testing Navigation for elderly people after hospital discharge. and Routine care. in people with Multimorbidity, run by Hospital de Clinicas de Porto Alegre at 1 site in Brazil.
Trial 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. Read more about this study
- Who is it for?
- Ages 60 years and older
- Conditions the study is for
- Multimorbidity
- What is being tested?
- Navigation for elderly people after hospital discharge. and Routine care.
- Type of treatment
- Lifestyle or therapy programme
- Could I receive a placebo?
- Yes, some participants may receive a placebo
- How many people
- 148 participants
- Where
- 1 siteBrazil
- Study dates
- 1 Jun 2026to 30 Mar 2028
- Phase
- Interventional
- Are there results?
- Not yet: the study is under way
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 60 years and older
- All sexes
- No healthy volunteers
- Adult, Older adult
Who may be able to join
- 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.
Who cannot join
- 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.
Trial locations and contacts
1 site in 1 country. Contact the study team or a site near you to ask about taking part.
Brazil1 site
Hospital de Clínicas de Porto Alegre
Porto Alegre, Rio Grande do Sul, 90410-000
Idiane Rosset, PHD, +555133598018, irosset@hcpa.edu.br
About this study
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.
Read the 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.
- Conditions
- Multimorbidity
- Being tested
- Navigation for elderly people after hospital discharge., Routine care.
- Keywords
- Aged, Patient Navigation., Multimorbidity, Comprehensive Health Care, Geriatric Nursing
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
Navigation for elderly people after hospital discharge.Behavioural
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.
Routine care.Other
Routine care.
| Study group | Role | What they receive |
|---|---|---|
| intervention | Experimental | submitted to the navigation protocol Receives: Behavioral: Navigation for elderly people after hospital discharge. |
| Control | Placebo comparator | The participant will receive the usual care, without additional supervision. Receives: Other: Routine care. |
What is being measured
The primary outcome is the main question the study is designed to answer.
Adherence to self-care
Assessed by the Brazilian version of the Self-Care of Chronic Illness Inventory
Measured: 6 months
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted22 Apr 2026
- Study start1 Jun 2026 (estimated)
- Primary completion30 Jul 2027 (estimated)
- Study completion30 Mar 2028 (estimated)
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Other trials for MultimorbidityStudies of the same condition, open and under way.
- More trials run by Hospital de Clinicas de Porto AlegreThe sponsor's other registered studies.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase N/A
- Primary purpose
- Supportive care
- Allocation
- Randomised
- Intervention model
- Parallel groups
- 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.
- Masking
- Single blind
- Who is masked
- Participant
- Enrolment
- 148 participants (estimated)
Sponsor and investigators
- Lead sponsor
- Hospital de Clinicas de Porto Alegre
- Sponsor type
- University, hospital or other
- Responsible party
- Sponsor
- Investigators
- Idiane Rosset, pdh, Principal investigator, Federal University of Rio Grande do Sul
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT07546006
- Sponsor's protocol ID
- 2026-0045
- Other IDs
- 95858326.9.0000.5327
- Acronym
- NAVIM
- Status last verified
- Apr 2026
- First submitted
- 15 Apr 2026
- Last updated
- 22 Apr 2026
- Results posted
- No
- Data monitoring committee
- Yes
- FDA-regulated drug
- No
- FDA-regulated device
- No
- Individual data sharing
- No
Study at a glance
From the registry record, last updated by the sponsor on 22 Apr 2026. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Navigation for Elderly People With Multiple Morbidity After Hospital Discharge.
- ClinicalTrials.gov ID
- NCT07546006
- Acronym / sponsor ID
- NAVIM / 2026-0045
- Conditions
- Multimorbidity
- Keywords
- Aged, Patient Navigation., Multimorbidity, Comprehensive Health Care, Geriatric Nursing
- Study type
- Interventional
- Recruitment status
- Not yet recruiting
- Enrolment
- 148 participants (estimated)
- Lead sponsor
- Hospital de Clinicas de Porto AlegreUniversity, hospital or other
- Study start
- 1 Jun 2026 (estimated)
- Primary completion
- 30 Jul 2027 (estimated)
- Study completion
- 30 Mar 2028 (estimated)
- First posted
- 22 Apr 2026 (actual)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
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.
Study design
- Primary purpose
- Supportive care
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- Single blind (participant)
- Number of arms
- 2
- 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.
| Arm | Type | Receives |
|---|---|---|
| intervention | Experimental | Behavioral: Navigation for elderly people after hospital discharge.submitted to the navigation protocol |
| Control | Placebo comparator | Other: Routine care.The participant will receive the usual care, without additional supervision. |
Who may qualify
- Ages
- 60 years and older
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Adult, Older adult
Key inclusion criteria (5 listed)
- 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.
Key exclusion criteria (4 listed)
- 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.
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| Navigation for elderly people after hospital discharge.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. | Behavioural | intervention |
| Routine care.Routine care. | Other | Control |
Primary outcome
Adherence to self-care
Time frame: 6 months
Assessed by the Brazilian version of the Self-Care of Chronic Illness Inventory
Results and safety
This study is still under way. Results are not available in the source record yet.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 22 Apr 2026.
- Individual participant dataSharing planned: No
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part.
Idiane Rosset, pdh principal investigator
Federal University of Rio Grande do Sul
1 site in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A study testing Navigation for elderly people after hospital discharge. and Routine care. in people with Multimorbidity, run by Hospital de Clinicas de Porto Alegre at 1 site in Brazil.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 5 inclusion and 4 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: opening soon, as of the sponsor's last update on 22 Apr 2026. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 1 site in Brazil. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. Some participants in this study may receive a placebo. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
This study is still under way. Results are not available in the source record yet.
How can a doctor refer a patient or contact the research team?
Contact Emily da Silva Eberhardt, Nurse researcher (+5551998921355, enfemilyeberhardt@gmail.com), or a site near the patient. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Adherence to self-care (time frame: 6 months). It is what the study was designed to measure, not a finding.
Where can I read the original study information?
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 22 Apr 2026.