Abstract
Background: Frailty leads to increased socioeconomic burden, higher healthcare costs and poorer quality of life. The SGH-GSH programme to delay frailty was piloted with exploration on care needs of SGH-GSH patients and the impact on acute care utilization.
Approach: In 2019, five hospitals, including Singapore General Hospital (SGH), launched pilot program for Geriatric Service Hub (GSH) funded by MOH. The hub aims to provide community-anchored and referral-gated geriatric services to promote early identification and layered intervention to frailty care. The SGH-GSH is a collaboration between the community nursing, population heath and geriatric medicine departments.
This descriptive analysis of the SGH-GSH program covers the period from July 2019 to July 2023. Shared care was anchored by geriatric-trained community nurses and supported by allied health professionals and geriatricians through joint visits and multidisciplinary case discussions. The core interventions included home-based geriatric assessments, nursing support, therapy service and case management or care coordination. As the GSH is a time-limited program, patients were transferred to community nurses for care continuity after 6 months. Data on unplanned readmissions (UR) were collected at 180D pre- and post-enrolment.
Results: A total of 918 adults living with mild frailty (Mean Age=80, SD=7.8; Mean CFS=4.8, SD=0.81). Nearly one third of participants (30.6%) lived alone. Hyperlipidemia (90.3%), stroke (65.9%) and hypertension (62.6%) were the top three chronic diseases that requiring follow up. Majority had voiding problems and urinary incontinence (79.2%) and high risk of fall (75.2%). 8.3% was assessed with cognitive impairment (AMT< 5) requiring further investigation. The average number of visits was 4.26 (SD = 3.48), about 20% requiring joint visits with AHPs. There was a trend of reduction for all-cause UR at 180D (p<0.13), but significant for those received minimal 3 visits (p<0.05).
Implications: The findings demonstrated the effectiveness of SGH-GSH model in reducing acute care utilization through assembled multi-disciplinary team efforts. For future sustainability, a place-based care model with multi-disciplinary geriatric services provides a promising solution by creating a supportive care ecosystem.