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. 2023;12(4):316-321.
doi: 10.14283/jfa.2023.23.

Geriatric Services Hub - A Collaborative Frailty Management Model between The Hospital and Community Providers

L F Tan  1 , J Teng, Z J Chew, A Choong, L Hong, R Aroos, P V Menon, J Sumner, K C Goh, S K Seetharaman
Affiliations

Geriatric Services Hub - A Collaborative Frailty Management Model between The Hospital and Community Providers

L F Tan et al. J Frailty Aging. 2023.

Abstract

Background: Frailty is an important geriatric syndrome especially with ageing populations. Frailty can be managed or even reversed with community-based interventions delivered by a multi-disciplinary team. Innovation is required to find community frailty models that can deliver cost-effective and feasible care to each local context.

Objectives: We share pilot data from our Geriatric Service Hub (GSH) which is a novel frailty care model in Singapore that identifies and manages frailty in the community, supported by a hospital-based multi-disciplinary team.

Methods: We describe in detail our GSH model and its implementation. We performed a retrospective data analysis on patient characteristics, uptake, prevalence of frailty and sarcopenia and referral rates for multi-component interventions.

Results: A total of 152 persons attended between January 2020 to May 2021. Majority (59.9%) were female and mean age was 81.0 ± 7.1 years old. One-fifth (21.1%) of persons live alone. Mean Charlson Co-morbidity Index was 5.2 ± 1.8. Based on the clinical frailty risk scale (CFS), 31.6% were vulnerable, 51.3% were mildly frail and 12.5% were moderately frail. Based on SARC-F screening, 45.3% were identified to be sarcopenic whilst 56.9% had a high concern about falling using the Falls-Efficacy Scale-International. BMD scans were done for 41.4% of participants, of which 58.7% were started on osteoporosis treatment. In terms of referrals to allied health professionals, 87.5% were referred for physiotherapy, 71.1% for occupational therapy and 50.7% to dieticians.

Conclusion: The GSH programme demonstrates a new local model of partnering with community service providers to bring comprehensive population level frailty screening and interventions to pre-frail and frail older adults. Our study found high rates of frailty, sarcopenia and fear of falling in community-dwelling older adults who were not presently known to geriatric care services.

Keywords: Frailty; community care; comprehensive geriatric assessment; multi-disciplinary team care.

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Conflict of interest statement

The authors declare no conflict of interest with respect to the research, authorship and/or publication of this article.

Figures

Figure 1
Figure 1
Picture of frailty screening programme in the community setting
See this image and copyright information in PMC

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