The goal of this trial is to evaluate whether a digital needs-assessment tool can improve care planning and outcomes for frail older adults (aged 60 years and above) hospitalized in Singapore. The tool is designed to identify patients' health and social service needs and support better care coordination after hospital discharge.
The main questions it aims to answer are:
* Does the use of a digital needs-assessment tool improve the identification and management of health and social service needs in frail older adults?
* Does this approach improve patient outcomes, such as quality of life, care satisfaction, and healthcare utilization after discharge?
Participants will:
* Respond to a baseline questionnaire
* Receive a personalized care plan based on identified needs by the tool
* Be followed up at 1 month and 3 months after discharge through surveys
* Some participants will receive additional follow-up phone calls to review care needs and service use
* A subset of participants will take part in interviews to share their care experiences