Improving Care for Frail Older Adults Using a Digital Needs Assessment Tool
Trial statusNot yet recruiting
Trial phaseNot applicable
Trial typeInterventional
Biological sexAll
Age60+
SponsorDuke-NUS Graduate Medical School
About this trial
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 criteria
This trial does not accept healthy volunteersQualifiers
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.
Disqualifiers
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.
Trial design
Design model
Parallel
Treatments tested in this trial
Core: SST-informed care planning
BehavioralThe 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
BehavioralParticipants will receive two structured post-discharge care coordination phone calls to support service uptake, address barriers, and facilitate follow-up on recommended services.
Treatment groups
200 Participants
are divided into 2 treatment groupsGroup A: SST + care coordination callsExperimental treatment 2 interventions
Group B: SST onlyExperimental treatment 1 intervention
Trial outcomes
Primary outcomes
1
Service initiation rate
The proportion of enrolled participants who successfully initiate at least one recommended health or social support service
Time frame
30 days after dischargeSecondary outcomes
1
Health-related quality of life
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.
Time frame
Baseline, 1-month and 3-month follow-ups2
Healthcare Utilisation
Healthcare service utilisation obtained from electronic medical records (EMR), including number of emergency department visits, hospital admissions, outpatient visits, and visits to healthcare professionals.
Time frame
180 days and 360 days post-discharge3
Usability of 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.
Time frame
24 hours after the first administered SST4
Intervention appropriateness (implementation outcome)
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.
Time frame
3-month follow-upOther outcomes
1
Healthcare costs
Healthcare utilisation costs and billing data obtained from EMR, including hospital and outpatient service costs.
Time frame
180 and 360 days post-discharge2
Unmet needs and service utilization
Assessment of assistance participants received since the last hospital discharge (18-item)
Time frame
1-month and 3-month follow-ups3
Caregiver burden (proxy participants only)
Caregiver burden measured using the 4-item Zarit Burden Interview, administered to proxies who are primary caregivers.
Time frame
Baseline, 1-month and 3-month follow-ups4
Resilience
Change in psychological resilience measured using the Connor-Davidson Resilience Scale (CD-RISC 10), with total scores ranging from 0 from 4. Higher scores indicate a higher level of psychological resilience.
Time frame
Baseline, 1-month and 3-month follow-upsSponsors and contacts
Click on the lead sponsor to view all of their trials.
Duke-NUS Graduate Medical School
Lead sponsor
Changi General Hospital
Collaborator
Agency for Integrated Care, Singapore
Collaborator
Source ClinicalTrials.gov
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