Journal of CardioVascular Insights
Open Access • Peer Reviewed • Quarterly Publication
A Project for the Post Hospitalization Care of Frail Patients. Tele-fra 30
Abstract
Frail patients discharged from internal medical wards have a high rate of readmission (30-35%) within
30 days. A pilot study was designed to determine whether telemedicine-based virtual visits can improve
outcomes for these patients. The study tools include appropriate staff training, a digital form for clinical and
care monitoring, and scores for quality of life and prognosis (EQ-5D, MPI). After discharge, frail patients
were divided into two groups: the study group (A) was monitored via telehealth by hospital medical staff,
while the control group (B) was placed under the care of community-based healthcare providers. To date,
remote assistance provided by internal medicine ward staff has made it possible to reduce short-term hospital
admissions (20% vs 41%) and deaths (2% vs 20%, p<0,05). Perceived quality of life (EQ-5D) and prognostic
score (MPI) have also improved in group A (T4 vs T0 p<0,001). The internal medicine department has a new
"tele" tool for transitioning frail elderly patients back to the community.
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© 2026 The Author(s). Published by WM Journals.
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