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

NCT07580690 · Status: NOT_YET_RECRUITING · Phase: NA · Type: INTERVENTIONAL · Enrollment: 200

Last updated 2026-05-12

No results posted yet for this study

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

Interventions

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.

BEHAVIORAL

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.

Sponsors & Collaborators

  • Changi General Hospital

    collaborator OTHER

  • Agency for Integrated Care, Singapore

    collaborator OTHER

  • Duke-NUS Graduate Medical School

    lead OTHER

Principal Investigators

  • Angelique Chan, Ph.D. · Duke-NUS Graduate Medical School

Study Design

Allocation
RANDOMIZED
Purpose
HEALTH_SERVICES_RESEARCH
Masking
SINGLE
Model
PARALLEL

Eligibility

Min Age
60 Years
Sex
ALL
Healthy Volunteers
No

Timeline & Regulatory

Start
2026-05-01
Primary Completion
2026-12-30
Completion
2027-12-30

Countries

  • Singapore

Study Locations

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Read the full study record

This page highlights key information. For complete eligibility criteria, study locations, investigator contacts, and the full protocol, visit the original record on ClinicalTrials.gov.

View NCT07580690 on ClinicalTrials.gov