Frail Elderly Patients, Frail Older Adults, Geriatric Syndromes
Conditions
Keywords
Frail Older Adults, Simple Segmentation Tool, Integrated Care, Care Coordination, Needs Assessment Tool, Health and Health-related Social Service
Brief summary
The goal of this trial is to evaluate whether a digital needs-assessment tool can improve care planning and outcomes for frail older adults (aged 60 years and above) hospitalized in Singapore. The tool is designed to identify patients' health and social service needs and support better care coordination after hospital discharge. The main questions it aims to answer are: * Does the use of a digital needs-assessment tool improve the identification and management of health and social service needs in frail older adults? * Does this approach improve patient outcomes, such as quality of life, care satisfaction, and healthcare utilization after discharge? Participants will: * Respond to a baseline questionnaire * Receive a personalized care plan based on identified needs by the tool * Be followed up at 1 month and 3 months after discharge through surveys * Some participants will receive additional follow-up phone calls to review care needs and service use * A subset of participants will take part in interviews to share their care experiences
Detailed description
Older adults with frailty frequently experience multiple medical, functional, and social challenges following hospital discharge. Evidence from the Health and Social Service Needs study indicates that patients discharged with unmet health and health-related social service (HASS) needs have poorer post-discharge outcomes, including increased healthcare utilization. While frailty screening is commonly used to identify high-risk patients, frailty status alone does not identify the specific actionable needs that could mitigate health deterioration or support community living. During hospitalization, assessments of these needs are typically conducted through referrals to medical social workers, patient navigators, case managers, or geriatricians. These referrals are discretionary and vary across providers and settings, contributing to inconsistent care delivery. Such approaches are resource-intensive and difficult to sustain under workforce constraints and may lead to missed identification of needs or delays in discharge, increasing the risk of unmet needs during care transitions. This study evaluates the implementation of a needs-based assessment approach using the Simple Segmentation Tool (SST), a brief digital instrument developed in Singapore by Matchar et al. (2017). The SST is designed to rapidly identify likely actionable HASS needs and support care planning and referral processes. The tool can be completed in approximately 2-3 minutes by trained healthcare professionals, including physicians, nurses, and case managers, and is supported by an algorithm developed by a multidisciplinary expert panel. Following enrollment, hospital staff will complete the SST based on participants' clinical and social circumstances. Care plans will be generated using outputs from the SST and reviewed with participants and/or their caregivers. If a participant is readmitted within three weeks of discharge, the SST assessment will be repeated following the subsequent discharge to ensure that care plans reflect updated or evolving needs. Participants who decline recommended services will remain enrolled in the study but will not be counted toward the target sample size of 200 participants. Participants will complete a baseline questionnaire during hospitalization and will be followed after discharge with structured surveys administered at one month and three months. These surveys will assess post-discharge outcomes related to health status, care experiences, and healthcare utilization. Qualitative interviews will also be conducted with a subset of patients and healthcare staff to explore experiences, perceived value, and implementation challenges associated with SST-guided care planning. To support care coordination, internal stakeholders and external community service providers, coordinated by the Agency for Integrated Care Care-Referral Team, will use a shared framework to facilitate service linkage and care transitions. Service activation and follow-up will be tracked, and any failures in linkage will be communicated to a central coordinating team to support resolution and continuity of care. Prior to the main study, a pilot phase involving up to 10 patient volunteers will be conducted to assess workflow feasibility, clarity of study materials, and questionnaire length. Pilot participants will provide informed consent, and data collected during this phase will not be included in research analyses. Feedback from the pilot will be used to refine study procedures and materials prior to full implementation.
Interventions
BEHAVIORALCore: SST-informed care planning
The Simple Segmentation Tool (SST) is used to assess multidimensional needs and generate individualized care recommendations. Participants receive SST-informed care plan and referral to appropriate health and social services.
BEHAVIORALAdditional telephone calls
Participants will receive two structured post-discharge care coordination phone calls to support service uptake, address barriers, and facilitate follow-up on recommended services.
Sponsors
Duke-NUS Graduate Medical School
Changi General Hospital
Agency for Integrated Care, Singapore
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
SINGLE (Subject)
Intervention model description
This study primarily uses a single-arm benchmarking design to evaluate the service initiation rate following implementation of the Simple Segmentation Tool (SST). All enrolled participants receive SST-informed needs assessment and care planning. In addition, an embedded randomized comparison is conducted to explore the impact of post-discharge care coordination calls. Participants are randomized in 1:3 ratio to receive either two follow-up phone calls or no additional calls. This randomized component is not related to the primary benchmarking outcome.
Eligibility
Sex/Gender
ALL
Age
60 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Patient participant: (i) Aged \>= 60 years at the time of recruitment; (ii) identified as frail, with a CFS score \>= 5 and/or modified HFRS intermediate and high frailty risk (mHFRS) score \>=5; (iii) Singapore citizens or permanent residents; (iv) able to speak and understand English, Chinese or Malay. * Proxy (when responding on behalf of eligible patients): (i) Relative or friend of the patient participant; (ii) Aged 21 years or older; (iii) Familiar with the older adult's health and social situation.
Exclusion criteria
* Patient participant: (i) Currently involved in another study or (ii) residents of nursing homes, or (iii) patients known to home hospice or home palliative care services with a life expectancy of less than 6 months. * Proxy: primary caregivers who are foreign domestic workers will be excluded from the study.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Service initiation rate | 30 days after discharge | The proportion of enrolled participants who successfully initiate at least one recommended health or social support service |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Health-related quality of life | Baseline, 1-month and 3-month follow-ups | Change in health-related quality of life measured using the 5-level EQ-5D (EQ-5D-5L). The EQ-5D-5L essentially consists of the EQ-5D descriptive system, where Index Score calculated based on country-specific preference (Singapore in this context) and the EuroQol Visual Analogue Scale (EQ-VAS) (range: 0 to 100) were reported. For both measures, higher scores indicate better health-related quality of life. |
| Healthcare Utilisation | 180 days and 360 days post-discharge | Healthcare service utilisation obtained from electronic medical records (EMR), including number of emergency department visits, hospital admissions, outpatient visits, and visits to healthcare professionals. |
| Usability of SST | 24 hours after the first administered SST | Usability was measured using the System Usability Scale (SUS), a 10-item instrument providing a global score from 0 to 100. Higher scores indicate better perceived usability. |
| Intervention appropriateness (implementation outcome) | 3-month follow-up | Assessed using the Intervention Appropriateness Measure (IAM) among staff involved in the care of patients using the SST, with total scores ranging from 4-20. Higher scores indicate greater appropriateness. |
| Quality of care and continuity | 1-month and 3-month follow-ups | Quality of care and continuity is measured using the adaptive Patient Continuity of Care Checklist (PCCQ). Items are rated on a 5-point Likert scale and scores range from 5-30. Higher scores indicate a higher level of perceived continuity of care. |
| Mortality | 180 and 360 days post-discharge | All-cause mortality assessed using electronic medical records (EMR), defined as death occurring from the time of enrollment. |
| Service quality of SST | 24 hours after the first administered SST | Perceived service quality was measured using an adaptive Electronic Service Quality Scale (E-S-QUAL) consisting of 19 items. Respondents first distributed 100 points across the four dimensions Efficiency, Fulfillment, System Availability, and Privacy, to reflect relative importance. Items were then rated on a 5-point Likert scale. Higher scores indicating a better perception of electronic service quality. |
| Care experience | 1-month and 3-month follow-ups | Patient-reported experience is measured using Client Satisfaction Questionnaire (CSQ-4). Total scores range from 4 to 16, where higher scores indicate greater satisfaction with care. |
| Intervention feasibility (implementation outcome) | 3-month follow-up | Assessed using the Feasibility of Intervention Measure (FIM) among staff involved in the care of patients using the SST. Total scores range from 4-20 and higher scores indicate greater feasibility. |
| Normalization process (implementation outcome) | 3-month follow-up | Assessed using the Normalisation Measure Development (NoMAD) among staff involved in the care of patients using the SST. Total scores range from 0-100. Higher scores indicate better normalization. |
| Intervention acceptability (implementation outcome) | 3-month follow-up | Measured by the Acceptability of Intervention Measure (AIM)among staff involved in the care of patients using the SST, with a total score ranging from 4-20. Higher scores indicate greater acceptability. |
Countries
Singapore
Contacts
CONTACTShenglin Zheng, Ph.D.
PRINCIPAL_INVESTIGATORAngelique Chan, Ph.D.
Duke-NUS Graduate Medical School
Outcome results
None listed