Improving Care for Frail Older Adults Using a Digital Needs Assessment Tool

Condition(s) studied

Investigational drug(s) / intervention(s)

Core: 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.

Additional 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.

Study 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

Eligibility

Primary outcome measure(s)

• Service initiation rate — 30 days after discharge
  The proportion of enrolled participants who successfully initiate at least one recommended health or social support service

Trial sites (1)

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