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

Older adults with frailty frequently experience multiple medical, functional, and social challenges following hospital discharge. Evidence from the Health and Social Service Needs study indicates that patients discharged with unmet health and health-related social service (HASS) needs have poorer post-discharge outcomes, including increased healthcare utilization. While frailty screening is commonly used to identify high-risk patients, frailty status alone does not identify the specific actionable needs that could mitigate health deterioration or support community living.

During hospitalization, assessments of these needs are typically conducted through referrals to medical social workers, patient navigators, case managers, or geriatricians. These referrals are discretionary and vary across providers and settings, contributing to inconsistent care delivery. Such approaches are resource-intensive and difficult to sustain under workforce constraints and may lead to missed identification of needs or delays in discharge, increasing the risk of unmet needs during care transitions.

This study evaluates the implementation of a needs-based assessment approach using the Simple Segmentation Tool (SST), a brief digital instrument developed in Singapore by Matchar et al. (2017). The SST is designed to rapidly identify likely actionable HASS needs and support care planning and referral processes. The tool can be completed in approximately 2-3 minutes by trained healthcare professionals, including physicians, nurses, and case managers, and is supported by an algorithm developed by a multidisciplinary expert panel.

Following enrollment, hospital staff will complete the SST based on participants' clinical and social circumstances. Care plans will be generated using outputs from the SST and reviewed with participants and/or their caregivers. If a participant is readmitted within three weeks of discharge, the SST assessment will be repeated following the subsequent discharge to ensure that care plans reflect updated or evolving needs. Participants who decline recommended services will remain enrolled in the study but will not be counted toward the target sample size of 200 participants.

Participants will complete a baseline questionnaire during hospitalization and will be followed after discharge with structured surveys administered at one month and three months. These surveys will assess post-discharge outcomes related to health status, care experiences, and healthcare utilization. Qualitative interviews will also be conducted with a subset of patients and healthcare staff to explore experiences, perceived value, and implementation challenges associated with SST-guided care planning.

To support care coordination, internal stakeholders and external community service providers, coordinated by the Agency for Integrated Care Care-Referral Team, will use a shared framework to facilitate service linkage and care transitions. Service activation and follow-up will be tracked, and any failures in linkage will be communicated to a central coordinating team to support resolution and continuity of care.

Prior to the main study, a pilot phase involving up to 10 patient volunteers will be conducted to assess workflow feasibility, clarity of study materials, and questionnaire length. Pilot participants will provide informed consent, and data collected during this phase will not be included in research analyses. Feedback from the pilot will be used to refine study procedures and materials prior to full implementation.

Inclusion criteria

• 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.

Exclusion criteria

• 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.