Improving outcomes in frail older adults with complex care needs in an ambulatory setting through timely, integrated person-centered care. A case for rapid access frailty clinics in Singapore.

Abstract

Background: Frailty is a significant risk factor for recurrent hospital admissions and emergency department presentations. Frail older adults are especially vulnerable to hospital related adverse outcomes recognisably functional decline, delirium, institutionalisation and mortality. Fragmentation of care resulting in poorly defined care responsibilities, together with the limitation of community resources to manage acute issues in this group of patients, increase the likelihood of them presenting to an acute care setting.
 Methods: A retrospective study evaluated frail older adults seen in an ambulatory Geriatric clinic in a government funded public hospital from 2021 to 2022. The aim of the study was to determine if timely evaluation of acute issues in an ambulatory setting could avoid a hospital admission or an emergency department presentation. 
 Results: Preliminary data in this study showed that (1) timely review of acute issues (<1 week from presentation) led to avoidance of hospital admission, emergency department presentation as well as admission in the next 30 days; (2) the common presentations successfully managed include worsening behavioral and psychological symptoms of dementia (BPSD), delirium, infections and falls; (3) majority of the patients seen were moderately to severely frail based on their clinical frailty score (CFS). Additionally, there was high level of patient and caregiver satisfaction reported.
 Conclusion: This study shows that hospital admissions and emergency department presentations can potentially be avoided in frail older adults whose acute medical issues are recognised and managed early. Important contributing factors to the effective management of these patients include: easy accessibility to the primary geriatrician involved, same day investigations, timely follow ups, good social/family support as well as the engagement of community services. Rapid access frailty clinics, a service model built upon the similar recognition that acute issues in frail older adults needed to be addressed promptly, has been described and shown to have benefit elsewhere. In Singapore, innovations in care delivery both within the hospital and in the community has become ever more crucial with an increasingly frail population and in already overwhelmed healthcare institutions. Rapid access frailty clinics can be a useful hospital-based service delivery model to improve care of our frail older adults.