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

"Intervention Phase 1: Feasibility Assessment Duration: January 7, 2025 - January 11, 2025 Participants: 10-15 patients~Description:~All involved services will be available to address and resolve potential issues.~The objective is to assess the feasibility of the program, ensuring that the intervention can be implemented as planned and identifying any practical or logistical challenges.~Phases 2 \& 3: Comprehensive Intervention Duration: January 12, 2025 - June 30, 2025 Participants: 200 patients~Description:~Full-scale implementation of the intervention. Includes interdisciplinary care, home follow-ups, therapeutic optimization, functional rehabilitation, health education, and psychosocial support.~Phase 4: Long-Term Follow-Up Duration: April 7, 2025 - June 30, 2026 Participants: 200 patients~Description:~Follow-up assessments at 3, 6, 9, and 12 months post-intervention. Evaluates hospital readmissi"