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
Qualifiers
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
Treatments tested in this trial
- Core: SST-informed care planning
- Additional telephone calls
Treatment groups
200 Participants
are divided into 2 treatment groupsSponsors and collaborators
Duke-NUS Graduate Medical School
Lead sponsor
Changi General Hospital
Collaborator
Agency for Integrated Care, Singapore
Collaborator
Source ClinicalTrials.gov