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

Pub Date : 2023-01-01 DOI:10.14283/jfa.2023.23

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

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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.

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老年服务中心——医院和社区提供者之间的脆弱性管理合作模式

背景虚弱是一种重要的老年综合征，尤其是在人口老龄化的情况下。脆弱性可以通过多学科团队提供的基于社区的干预措施来管理甚至扭转。需要创新，以找到能够为每个地方提供成本效益高且可行的护理的社区脆弱性模型。目的我们分享来自我们的老年服务中心（GSH）的试点数据，这是新加坡一种新的虚弱护理模式，在医院多学科团队的支持下，识别和管理社区中的虚弱。方法详细描述我们的GSH模型及其实现。我们对患者特征、摄入、虚弱和少肌症的患病率以及多成分干预的转诊率进行了回顾性数据分析。结果2020年1月至2021年5月，共有152人参加。女性占多数（59.9%），平均年龄81.0±7.1岁。五分之一（21.1%）的人独自生活。平均Charlson合并症指数为5.2±1.8。根据临床虚弱风险量表（CFS），31.6%的人易感，51.3%的人轻度虚弱，12.5%的人中度虚弱。根据严重急性呼吸系统综合征-综合征筛查，45.3%的患者被确定为肌肉萎缩，而56.9%的患者使用国际跌倒疗效量表高度担心跌倒。41.4%的参与者进行了骨密度扫描，其中58.7%的参与者开始接受骨质疏松症治疗。在转诊给专职卫生专业人员方面，87.5%的人被转诊接受物理治疗，71.1%的人接受职业治疗，50.7%的人转诊给营养师。结论GSH计划展示了一种新的地方模式，即与社区服务提供商合作，为体弱前期和体弱老年人提供全面的人群层面的虚弱筛查和干预措施。我们的研究发现，在目前不为老年护理服务所知的社区老年人中，虚弱、少肌症和害怕跌倒的比率很高。电子补充材料补充材料可在本文的在线版本中获得，网址为10.14283/jfa.2023.23。

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