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Improving Care for Frail Older Adults Using a Digital Needs Assessment Tool
Sponsor: Duke-NUS Graduate Medical School
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
Official title: Integrating Health and Social Service Needs for Frail Elders at Point of Care: Development and Evaluation of an IT-based Digital Needs-assessment Tool
Key Details
Gender
All
Age Range
60 Years - Any
Study Type
INTERVENTIONAL
Enrollment
200
Start Date
2026-05-01
Completion Date
2027-12-30
Last Updated
2026-05-12
Healthy Volunteers
No
Interventions
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.
Locations (1)
Changi General Hospital (CGH)
Singapore, Singapore