Frailty is a state of increased vulnerability due to an age-associated decline in function and reserve such that the ability to cope with acute stressors is compromised (1). Frail individuals are at higher risk of negative health outcomes such as hospitalisations, disability, institutionalisation and mortality (2). The prevalence of frailty varies globally but increases with age and ranges between 4 to 60% in community-dwelling older adults (3). Singapore has a rapidly ageing population with 1 in 4 persons predicted to be 65 years and older in 20304.The prevalence of frailty locally is 27% in medical outpatient clinics (5) and 6% in the community (6). Frailty is potentially reversible with targeted interventions such as nutrition, exercise and medication reconciliation (2, 7, 8).

The multifactorial nature of frailty necessitates multifactorial, multi-disciplinary interventions tailored to results of a comprehensive assessment such as the comprehensive geriatric assessment (CGA) (9). There is a growing number of innovative care models which aim to provide comprehensive care to improve frail older adults’ health and social outcomes (8). Comprehensive and integrated care across settings can reduce hospitalisation and preserve functional mobility (7, 9, 11). Enabling ageing-in-place and helping older adults remain at home is a priority of many policymakers in countries with rapidly ageing populations10. However, the success of such programmes requires coordination across administrative, financial, social service and healthcare sectors. As such, models must account for the local healthcare and socio-cultural contexts and adapting existing international models (8, 9) remains a challenge especially in a multi-player system. More care models adapted to local needs and contexts are needed.

Against this backdrop, Singapore’s Ministry of Health (MOH) initiated the Geriatric Service Hub (GSH) to enhance identification and management of frailty in the community. The main goals of GSH are to increase health-span, minimise disability and promote ageing in place (12). The GSH was developed in anticipation of the growing complex care needs of a rapidly ageing population. GSH was also driven by a need to reduce fragmented care, due to the poor coordination between private and public primary care and tertiary care sectors, and increase accessibility of frailty services to older adults. The main aims of GSH are:

1.

Prompt identification of pre-frail and frail elderly in the community

2.

Making geriatric services accessible and affordable to residents

3.

Timely interventions and referrals

4.

Enhance capabilities of community partners in the area of geriatric care

This paper describes the implementation of a community frailty screening and intervention programme led by a hospital-based multi-disciplinary team in collaboration with community partners. We retrospectively analyse the pilot data from this programme and highlight the implications for future community frailty programmes and healthcare planning policies especially for an ageing population.

Methodology

We conducted a retrospective evaluation of the GSH programme over a 17-month period. The number of referrals from community partners, number of participants enrolled, profile of the participants including basic demographics, frailty assessment, medical co-morbidities, functional and cognitive status of these participants were recorded. Referrals to the various components of the intervention were also recorded. Basic descriptive statistics of the programme participants are presented as frequencies (n) and percentages (%). Continuous variables are presented as mean ± standard deviation.

Development of the GSH programme

The GSH was established in 2019 to screen and treat frailty amongst community-dwelling older adults aged 65 years and above in the Queenstown district, which is served by Alexandra Hospital. Queenstown has a large elderly population; 18.2% of residents are ≥ 65 years.

The GSH model partners with various community service providers including the regional primary care polyclinic and senior activity centres (Figure 1). A collaborative approach was undertaken in designing the programme with our community partners. The eligibility criteria, assessments and interventions were determined by the hospital-based multi-disciplinary team. The site set-up, referral process, inventory and equipment storage were jointly discussed and adapted based on each site’s availability and resources. Regular consultation and feedback with community partners was done to address any issues that arose during the implementation process. There was no financial incentive given to community partners for use of their premises and referral of older adults. Participation by community partners is thus due to their buy-in and belief in the benefits of the programme for their institutions and the persons whom they serve. Regular joint education and multi-disciplinary meetings between the hospital-based healthcare team and community partners are conducted to build up the capability of community partners in geriatric care and service. Thus, the underlying collaborative effort is one of building stakeholdership amongst all the partners for mutual benefit.

Figure 1

Picture of frailty screening programme in the community setting

The GSH programme

The eligibility criteria for participation were pre-frail to frail older adults aged 65 years and older who were not receiving any geriatric care services. Exclusion criteria included not having a life limiting illness with life expectancy <12 months, malignancy on active chemotherapy and being on home medical services. The Clinical Frailty Scale (CFS) tool was used to screen for frailty (14). Screening and referrals are done by primary care physicians and community partners (Supplementary Figure 1). Training was conducted by the hospital geriatricians to standardise the screening process before the community partners began recruitment. Informed consent was obtained prior to enrolment into the programme.

Intervention

The intervention is modelled on other community multi-component frailty intervention trials (7, 15, 16). The overarching principle is that of providing variable multi-component interventions based on findings from a comprehensive geriatric assessments (CGA). A mobile geriatric care team comprising nurses, case managers, pharmacists and doctors conduct weekly sessions at these community outposts. All persons enrolled in this community frailty screening programme undergo medical assessment and CGA on the first visit. The main domains include: clinical (medical history, Charlson comorbidity index, medication review), functional (modified Barthel index, SARC-F score), cognitive (abbreviated mental test and Singapore-modified mini-mental state examination (SM-MMSE)), falls (Falls Efficacy Scale International (FESI)), mood (15 item Geriatric Depression Scale (GDS-15), nutrition (3-minute nutrition screen), social and caregiver stress (22-item Zarit Burden Interview (ZBI)). Access to electronic medical records is provided via a secure virtual private network (VPN).

Thereafter, participants will be referred for individualised multi-component interventions as deemed relevant by the assessing geriatrician and in consultation with participants and their caregivers. These interventions include:

Physical activity: physiotherapists conduct an individual assessment to identify needs and make recommendations. These include referral to day rehabilitation centres if regular rehabilitation is required. For example, gymtonic (17) which is a structured strength-training programme comprising 30-minute sessions twice a week using software enabled, air-powered gym machines available at various locations across the country.

Home environment and assistive aid assessment: occupational therapists conduct home environment and assistive aid review. The national housing development board (HDB) has an enhancement for active seniors (EASE) scheme (18) that provides highly subsidised home modifications such as ramps, grab bars installation and slip-resistant treatment to bathroom floor tiles. There is a national senior mobility and enabling fund (SMF) which provides subsidies to older adults to purchase assistive devices such as walking aids, wheelchairs, commodes, hearing aids and spectacles. These schemes require financial assessment to ascertain subsidy levels and certification of functional status by healthcare professionals. The GSH team will encourage and assist patients to apply for these schemes as necessary.

Nutrition: dieticians conduct a nutritional assessment and make recommendations as necessary. This would include weight reduction if relevant and/or increased protein and calcium intake.

Health education: public education talks are conducted by the GSH team at regular intervals in collaboration with community partners. Healthy habits e.g. smoking cessation and alcohol control are also promoted and reinforced during the regular clinical reviews.

Medication reconciliation and compliance: the assessing physician will perform a baseline medication review. For complex cases, the pharmacist on the team will be referred for medication reconciliation and counselling. Where necessary, a pharmacy outreach team will work with individuals and caregivers to increase compliance through education, pill-boxing and application for medication packing services.

Allied health interventions: where relevant, referrals to psychology, speech therapy, podiatry and audiology are made as determined by the assessing geriatrician. Owing to the low frequency of referrals to these services, in contrast to referrals to dietetics, physical and occupational therapy, these sessions are conducted in the hospital.

Advanced care planning (ACP): this is opportunistically initiated during consultations. With the regular reviews planned for the duration of the programme, ACP is introduced and an information booklet provided for participants to consider and revert on their decision to proceed with formal discussion and documentation. Briefly, ACP entails planning for future health and personal care and involves discussing one’s personal beliefs, values and goals of care with their loved ones and healthcare providers. The GSH setting is conducive for this given the community-based setting and holistic review that participants enrol themselves to receive. Trained ACP facilitators conduct the ACP discussions at the respective community sites.

The multi-disciplinary healthcare team are hospital-based but conduct therapy and counselling sessions at the respective community sites to make these services accessible to older adults. Blood tests and scans can be arranged which would be performed at the supporting acute hospital.

Participants are followed up at 0, 3, 6, 9 and 12 months. The geriatrician does a comprehensive assessment at the first visit and reviews patients at 3 and 12 months. The geriatric nurse conducts the rest of the interval reviews and assessments and will highlight any issues to the geriatrician as relevant. Regular multi-disciplinary team meetings are held to comprehensively manage persons as well as to educate and enhance cooperation with community service partners. At the end of one year of follow up, participants will be discharged back to the community provider, primary care or followed up at a geriatric specialist clinic as determined during the final assessment by the geriatrician.

This study received ethics approval from the NHG Domain Specific Review Board (DSRB Ref: 2021/00839)