Integrating Health and Social Service Needs for Frail Elders at Point of Care: Development and Evaluation of an IT-based 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.