Integrating Health and Social Service Needs for Frail Elders at Point of Care: Development and Evaluation of an IT-based Digital Needs-assessment Tool

Inclusion Criteria

Inclusion Criteria: * Patient participant: (i) Aged \>= 60 years at the time of recruitment; (ii) identified as frail, with a CFS score \>= 5 and/or modified HFRS intermediate and high frailty risk (mHFRS) score \>=5; (iii) Singapore citizens or permanent residents; (iv) able to speak and understand English, Chinese or Malay. * Proxy (when responding on behalf of eligible patients): (i) Relative or friend of the patient participant; (ii) Aged 21 years or older; (iii) Familiar with the older adult's health and social situation. Exclusion Criteria: * Patient participant: (i) Currently involved in another study or (ii) residents of nursing homes, or (iii) patients known to home hospice or home palliative care services with a life expectancy of less than 6 months. * Proxy: primary caregivers who are foreign domestic workers will be excluded from the study.