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

NCT07580690 | Not Yet Recruiting

• 2 other identifiers: CIRB: 2024-2130MOH-001199-00
• Study Type: interventional
• Target: 200
• Locations: 1 country
• Sites: 1

Brief 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

Conditions

Frail Elderly Patients; Geriatric Syndromes; Frail Older Adults

Keywords

Frail Older Adults; Simple Segmentation Tool; Integrated Care; Care Coordination; Needs Assessment Tool; Health and Health-related Social Service

Outcome Measures

Primary Outcomes (1)

• Service initiation rate

  The proportion of enrolled participants who successfully initiate at least one recommended health or social support service

  30 days after discharge

Secondary Outcomes (11)

• Health-related quality of life

  Baseline, 1-month and 3-month follow-ups

• Healthcare Utilisation

  180 days and 360 days post-discharge

• Usability of SST

  24 hours after the first administered SST

• Intervention appropriateness (implementation outcome)

  3-month follow-up

• Quality of care and continuity

  1-month and 3-month follow-ups

Other Outcomes (10)

• Healthcare costs

  180 and 360 days post-discharge

• Unmet needs and service utilization

  1-month and 3-month follow-ups

• Caregiver burden (proxy participants only)

  Baseline, 1-month and 3-month follow-ups

Study Arms (2)

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.

Behavioral: Core: SST-informed care planning; Behavioral: Additional telephone calls

SST only

EXPERIMENTAL

Participants will receive a digital needs assessment during hospitalization and a personalized care plan.

Behavioral: Core: SST-informed care planning

Interventions

Core: SST-informed care planning BEHAVIORAL

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.

SST + care coordination calls; SST only

Additional telephone calls BEHAVIORAL

Participants will receive two structured post-discharge care coordination phone calls to support service uptake, address barriers, and facilitate follow-up on recommended services.

SST + care coordination calls

Eligibility Criteria

• Age: 60 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• 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.

You may not qualify if:

• 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.

Sponsors & Collaborators

• Duke-NUS Graduate Medical School: lead
• Changi General Hospital: collaborator
• Agency for Integrated Care, Singapore: collaborator

Study Sites (1)

Changi General Hospital (CGH)

Singapore, Singapore

Location

Related Publications (5)

• Chong JL, Low LL, Chan DYL, Shen Y, Thin TN, Ong MEH, Matchar DB. Can we understand population healthcare needs using electronic medical records? Singapore Med J. 2019 Sep;60(9):446-453. doi: 10.11622/smedj.2019012. Epub 2019 Jan 15.

  PMID: 30644525 BACKGROUND

• Chong JL, Matchar DB. Benefits of Population Segmentation Analysis for Developing Health Policy to Promote Patient-Centred Care. Ann Acad Med Singap. 2017 Jul;46(7):287-289. No abstract available.

  PMID: 28821893 BACKGROUND

• Chong JL, Low LL, Matchar DB, Malhotra R, Lee KH, Thumboo J, Chan AW. Do healthcare needs-based population segments predict outcomes among the elderly? Findings from a prospective cohort study in an urbanized low-income community. BMC Geriatr. 2020 Feb 27;20(1):78. doi: 10.1186/s12877-020-1480-9.

  PMID: 32103728 BACKGROUND

• Matchar D, Vashishtha R, Jing X, Sivapragasam N, Sim R, Chong JL. Development and validation of a brief assessment of normative health and health-related social needs using the Simple Segmentation Tool. BMC Health Serv Res. 2025 Feb 11;25(1):230. doi: 10.1186/s12913-025-12364-x.

  PMID: 39934828 BACKGROUND

• Chong JL, Matchar DB, Tan Y, Sri Kumaran S, Gandhi M, Ong MEH, Wong KS. Population Segmentation Based on Healthcare Needs: Validation of a Brief Clinician-Administered Tool. J Gen Intern Med. 2021 Jan;36(1):9-16. doi: 10.1007/s11606-020-05962-4. Epub 2020 Jun 30.

  PMID: 32607929 BACKGROUND

Study Officials

• Angelique Chan, Ph.D.

  Duke-NUS Graduate Medical School

  PRINCIPAL INVESTIGATOR

Central Study Contacts

Shenglin Zheng, Ph.D.

CONTACT

6580325886; sz61@nus.edu.sg

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: SINGLE
• Who Masked: PARTICIPANT
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Associate Professor

Model Details: This study primarily uses a single-arm benchmarking design to evaluate the service initiation rate following implementation of the Simple Segmentation Tool (SST). All enrolled participants receive SST-informed needs assessment and care planning. In addition, an embedded randomized comparison is conducted to explore the impact of post-discharge care coordination calls. Participants are randomized in 1:3 ratio to receive either two follow-up phone calls or no additional calls. This randomized component is not related to the primary benchmarking outcome.

Study Record Dates

• First Submitted: April 14, 2026
• First Posted: May 12, 2026
• Study Start: May 1, 2026
• Primary Completion (Estimated): December 30, 2026
• Study Completion (Estimated): December 30, 2027
• Last Updated: May 12, 2026

Record last verified: 2026-05

Data Sharing

• IPD Sharing: Will not share

Locations

SG (1)