[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"health-study-detail:100640551":3},{"organization":4,"armGroups":7,"interventions":19,"overallOfficials":30,"centralContacts":34,"locations":40,"responsibleParty":56,"collaborators":59,"id":64,"slug":65,"hasResults":66,"nctId":67,"briefTitle":68,"officialTitle":69,"acronym":70,"eligibilityCriteria":71,"healthyVolunteers":66,"sex":72,"minAge":73,"maxAge":25,"enrollmentInfo":74,"targetDuration":25,"studyType":77,"phases":78,"briefSummary":80,"conditions":81,"keywords":85,"overallStatus":91,"whyStopped":25,"lastUpdateSubmitDate":92,"lastUpdatePostDateStruct":93,"startDateStruct":96,"completionDateStruct":98,"leadSponsor":100,"locationsCount":101},{"fullName":5,"class":6},"Duke-NUS Graduate Medical School","OTHER",[8,15],{"label":9,"type":10,"description":11,"interventionNames":12},"SST + care coordination calls","EXPERIMENTAL","Participants will receive a digital needs assessment during hospitalization and a personalized care plan. After discharge, participants will be randomized in a 1:3 ratio. Participants will receive two follow-up calls from care coordinators to review care needs and support care coordination.",[13,14],"Behavioral: Core: SST-informed care planning","Behavioral: Additional telephone calls",{"label":16,"type":10,"description":17,"interventionNames":18},"SST only","Participants will receive a digital needs assessment during hospitalization and a personalized care plan.",[13],[20,26],{"type":21,"name":22,"description":23,"armGroupLabels":24,"otherNames":25},"BEHAVIORAL","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.",[9,16],null,{"type":21,"name":27,"description":28,"armGroupLabels":29,"otherNames":25},"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.",[9],[31],{"name":32,"affiliation":5,"role":33},"Angelique Chan, Ph.D.","PRINCIPAL_INVESTIGATOR",[35],{"name":36,"role":37,"phone":38,"phoneExt":25,"email":39},"Shenglin Zheng, Ph.D.","CONTACT","6580325886","sz61@nus.edu.sg",[41],{"facility":42,"status":25,"city":43,"state":25,"zip":25,"country":43,"countryCode":44,"cosmosGeoPoint":45,"geoPoint":50,"contacts":51},"Changi General Hospital (CGH)","Singapore","SG",{"type":46,"coordinates":47},"Point",[48,49],103.85007,1.28967,{"lat":49,"lon":48},[52],{"name":53,"role":37,"phone":54,"phoneExt":25,"email":55},"Barbara H Rosario, FRCP (Lond)","6569366528","rosario.barbara.helen@singhealth.com.sg",{"type":33,"investigatorFullName":57,"investigatorTitle":58,"investigatorAffiliation":5,"oldNameTitle":25,"oldOrganization":25},"Angelique Chan","Associate Professor",[60,62],{"name":61,"class":6},"Changi General Hospital",{"name":63,"class":6},"Agency for Integrated Care, Singapore","100640551","improving-care-for-frail-older-adults-using-a-digital-needs-assessment-tool-100640551",false,"NCT07580690","Improving Care for Frail Older Adults Using a Digital Needs Assessment Tool","Integrating Health and Social Service Needs for Frail Elders at Point of Care: Development and Evaluation of an IT-based Digital Needs-assessment Tool","Frailty","Inclusion Criteria:\n\n* Patient participant: (i) Aged \\>= 60 years at the time of recruitment; (ii) identified as frail, with a CFS score \\>= 5 and\u002For 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.\n* 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.\n\nExclusion Criteria:\n\n* 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.\n* Proxy: primary caregivers who are foreign domestic workers will be excluded from the study.","ALL","60 Years",{"count":75,"type":76},200,"ESTIMATED","INTERVENTIONAL",[79],"NA","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.\n\nThe main questions it aims to answer are:\n\n* Does the use of a digital needs-assessment tool improve the identification and management of health and social service needs in frail older adults?\n* Does this approach improve patient outcomes, such as quality of life, care satisfaction, and healthcare utilization after discharge?\n\nParticipants will:\n\n* Respond to a baseline questionnaire\n* Receive a personalized care plan based on identified needs by the tool\n* Be followed up at 1 month and 3 months after discharge through surveys\n* Some participants will receive additional follow-up phone calls to review care needs and service use\n* A subset of participants will take part in interviews to share their care experiences",[82,83,84],"Frail Elderly Patients","Geriatric Syndromes","Frail Older Adults",[84,86,87,88,89,90],"Simple Segmentation Tool","Integrated Care","Care Coordination","Needs Assessment Tool","Health and Health-related Social Service","NOT_YET_RECRUITING","2026-05-05",{"date":94,"type":95},"2026-05-12","ACTUAL",{"date":97,"type":76},"2026-05-01",{"date":99,"type":76},"2027-12-30",{"name":5,"class":6},1]