An Intrinsic Capacity Identification and Management Programme for Older Adults in Singapore's Primary Care (IMPACTFrail)

Implementing the National Frailty Policy in Singapore's Primary Care: A Pilot Feasibility Study of The Intrinsic Capacity ProMotion in PrimAry Care for The Frail Program (IMPACTFrail)

The IMPACTFrail program is an intrinsic capacity (IC) identification and management program for mildly frail older adults. Specifically, it delivers the three-tier approach recommended in the National Frailty Strategy Policy Report. The program's core functions include the segmentation of older persons using the Clinical Frailty Scale (CFS) score followed by secondary IC screening for CFS 4 to 5 (Tier 1), follow-up clinical assessment to confirm IC losses (Tier 2) and needs-directed management and tracking of their health (Tier 3).

The investigator aims to conduct a multi-site feasibility study on a small group of older adult study participants (n=30 per polyclinic).

The feasibility study has a few components. First, a qualitative study will assess its feasibility (implementation, appropriateness, acceptability, practicality, adaptability) as perceived by older adults, healthcare providers, and healthcare administrators. Second, the investigator aims to collect process indicators to track its implementation progress. Third, program costs will be estimated. Fourth, the investigator will develop a logic model and theory of change, and cluster-specific detailed written program descriptions. Lastly, the investigator aims to triangulate the findings and assess the feasibility for larger-scale implementation. This study is guided by implementation science frameworks and guidelines for conducting feasibility studies.

Study Overview

• Status: Not yet recruiting
• Conditions: Frailty; Healthy Ageing
• Intervention / Treatment: Other: The IMPACTFrail programme

Detailed Description

Background:

The broad goal for older adults is to age well and have healthy ageing. WHO defines healthy ageing as "the process of developing and maintaining the functional ability that enables wellbeing in older age." Functional ability is about having the capabilities that enable all people to be and do what they have reason to value.

Frailty is a clinically recognisable state whereby an older person's ability to cope with daily or acute stressors is compromised as a result of vulnerability from age-related deterioration in physiological reserves and function across multiple organ systems. Frailty is associated with negative health outcomes and is expected to increase in Singapore's ageing population. The National Frailty Strategy Policy Report published in 2023 serves to guide the Singapore Ministry of Health (MOH) Frailty Policy Implementation Workgroup in implementing the National Frailty Policy (NFP). One of the gaps identified in the report was the need for coordinated care and continuity of care across health and social service providers for frail older adults. To address this gap in Singapore's primary care setting, the IMPACTFrail program's core functions are to conduct segmentation of older people by using the Clinical Frailty Scale (CFS) score followed by secondary intrinsic capacity (IC) screening of six domains (locomotion, vision, hearing, vitality, cognition, psychological capacity) for CFS 4 and 5 (Tier 1), follow-up assessments based on IC deficits detected at screening (Tier 2), and coordination, management, and tracking (Tier 3). This study aims to co-develop IMPACTFrail's intervention components and implementation strategies in a small number of polyclinics and test its feasibility using implementation research in real-world local contexts.

Methods:

Prior to this pilot feasibility study, the investigators co-developed the innovation and implementation strategies among GERI, polyclinic cluster representatives, and implementers. This will be guided by the UK Medical Research Council's Framework (MRC) for developing and evaluating complex interventions and Framework of Actions for Intervention Development (FAID). Informal FGDs and interviews with stakeholders were conducted and the findings used to inform the development of the innovation. ERIC strategies will be selected to address CFIR barriers identified from the FGDs/interviews and specify and develop them.

Here, the investigators aim to conduct a multi-site feasibility study, with a few components. Each polyclinic has highly contextualised barriers, workflows, and infrastructure. Thus, each polyclinic is conceptualised as a single site for feasibility testing. There is no comparator arm.

First, FGDs/IDIs will be conducted to assess the program's feasibility (implementation, acceptability, practicality, adaptability) as perceived by older adults, healthcare providers, and healthcare administrators.

Second, the investigators aim to collect process indicators to track the program's implementation progress.

Third, program costs will be estimated.

Fourth, the investigators will develop a logic model and theory of change, and cluster-specific detailed written program descriptions.

Lastly, the investigators aim to triangulate our findings and assess the feasibility for larger-scale implementation.

This study is guided by implementation science frameworks and guidelines for conducting feasibility studies.

Discussion:

This project aims to improve the lives of older people through early detection and management of IC deficits for those with mild frailty (CFS 4-5) in primary care. This promotes longer-term outcomes including functional ability, improved quality of life, reduced healthcare use, and lower mortality.

Additionally:

First, the project translates evidence on the optimisation of IC and functional ability for healthy ageing to practice and policy in Singapore's primary care. Second, there is knowledge creation. This study contributes to the local evidence on screening and management strategies for delaying frailty progression by addressing IC deficits in frail older persons. The investigators inform the adaptations to implement the WHO ICOPE framework in local primary care contexts. Additionally, the project contributes to a better understanding on the optimisation of resources to groups who may benefit the most, by targeting CFS 4 and 5 for IC screening and delivering resource-intensive assessment and downstream interventions to this subgroup. Third, this study involves engaging all three clusters from the outset to accelerate national-level implementation and scaling up.

Additionally, to increase the likelihood of scalability, the investigators will involve 3 clusters and 1-2 polyclinics from each cluster. Fourth, the study offers opportunities for knowledge exchange.

Lastly, the project is aligned with national strategies like HealthierSG (informs frailty protocols for management in primary care), Age Well SG (enables frail community-dwelling persons to age in place), and the 2023 Action Plan for Successful Ageing (optimising IC and functional ability through a health program).

• Study Type: Observational
• Enrollment (Estimated): 180

Contacts and Locations

• Study Contact: Name: Grace Sum, PhD; Phone Number: (+65) 6807 8020; Email: sum.grace.ce@geri.com.sg

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: Yes

• Sampling Method: Non-Probability Sample

Study Population

Older adults will be polyclinic patients aged 60 years and above with CFS score 4 or 5 as assigned by a trained healthcare provider at the polyclinic. They should not have done any comprehensive geriatric assessment or be currently receiving geriatric specialist outpatient services.

Healthcare staff can be polyclinic healthcare providers (e.g., polyclinic doctors, nurses, care coordinators, care managers, medical social workers). Healthcare administrators would be from the polyclinic leadership team, who are decision-makers who have the authority to make implementation decisions and are familiar with the overall frailty and IC management strategies in primary care in Singapore.

Description

Older Adults

Inclusion Criteria:

• being a patient of the polyclinic site
• aged 60 years and above
• Clinical frailty score (CFS) of 4 - 5
• Not done comprehensive geriatric assessment (CGA) in the past 12 months (based on available medical records or self-report)
• Not a current patient of geriatric specialist outpatient clinic (based on available medical records or self-report).

Exclusion Criteria:

• Do not meet inclusion criteria above

Healthcare Staff (for qualitative study)

Inclusion Criteria:

• aged 21 years and above
• Involved in the IMPACTFrail program as an implementer and/or a healthcare administrator with authority to make implementation decisions.

Exclusion Criteria:

• Do not meet inclusion criteria above

Study Plan

How is the study designed?

Number of groups / cohorts

1

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Older Adults (programme recipients); These are the recipients of the new programme in this feasibility study. Main study components of direct involvement. Qualitative - Focus group discussions or in-depth interviews with programme recipients Quantitative - Monitoring process indicators	Other: The IMPACTFrail programme; The IMPACTFrail programme

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Qualitative study 1	What will be measured: Deviations to the intended execution of the programme and implementation strategies and reasons for changes made. How will it be measured: Via in-depth interviews (IDIs) and focus group discussions (FGDs) with healthcare administrators and healthcare providers. All participants for the qualitative study will be identified through purposive sampling. We will adopt the Rapid Qualitative Inquiry (RQI) approach in data analysis.	Mar 2025 - Feb 2026
Qualitative study 2	What will be measured: Barriers/facilitators of implementing/receiving the programme and its implementation strategies. How will it be measured: Via in-depth interviews (IDIs) and focus group discussions (FGDs) with healthcare administrators, healthcare providers, and older adults. All participants for the qualitative study will be identified through purposive sampling. We will adopt the Rapid Qualitative Inquiry (RQI) approach in data analysis.	Mar 2025 - Feb 2026
Qualitative study 3	What will be measured: Perspectives on the ability to deliver innovation with given resources (manpower, infrastructure, IT, others). How will it be measured: Via in-depth interviews (IDIs) and focus group discussions (FGDs) with healthcare administrators and healthcare providers. All participants for the qualitative study will be identified through purposive sampling. We will adopt the Rapid Qualitative Inquiry (RQI) approach in data analysis.	Mar 2025 - Feb 2026
Qualitative study 4	What will be measured: Suggestions on how to improve the implementation of the programme for scalability and sustainability. How will it be measured: Via in-depth interviews (IDIs) and focus group discussions (FGDs) with healthcare administrators and healthcare providers. All participants for the qualitative study will be identified through purposive sampling. We will adopt the Rapid Qualitative Inquiry (RQI) approach in data analysis.	Mar 2025 - Feb 2026
Programme cost	The aim is to inform the funding of resources (developmental cost e.g., training, new materials, innovation cost and cost of implementation strategies needed to scale up the programme). Programme costs will be derived by aggregating expenditures from financial statements on operating expenses, manpower, training, and equipment cost incurred, and obtaining the time spent by healthcare workers to actualise the delivery of the program.	Mar 2025 - Feb 2026
Logic model and theory of change	What will be measured: The output is a single figure. We aim to depict a visual representation of the resources, key activities, outputs, outcomes, and plausible causal pathways connecting them.	Mar 2025 - Feb 2026
Written programme description	What will be reported: The investigators will report the narrative detailed description of the programme. How will it be measured or reported: The frameworks used are TIDIER and AIMD.	Mar 2025 - Feb 2026
Process indicators	What will be measured: Number of older adults with Clinical frailty scale (CFS) score 4-5, number of older adults who completed intrinsic capacity screening, number of older adults who actualised follow-up appointments. How will it be measured: Data collection will be from healthcare providers on the ground.	Mar 2025 - Feb 2026
Fidelity of implementation strategy: Educational meetings, Part 1	What will be measured: Actor: Who executed the educational meetings. How will it be measured: Data collection will be from healthcare providers on the ground.	Mar 2025 - Feb 2026
Fidelity of implementation strategy: Educational meetings, Part 2	What will be measured: Action target: Who attended the meetings How will it be measured: Data collection will be from healthcare providers on the ground.	Mar 2025 - Feb 2026
Fidelity of implementation strategy: Educational meetings, Part 3	What will be measured: Temporality: Frequency of meetings How will it be measured: Data collection will be from healthcare providers on the ground.	Mar 2025 - Feb 2026
Fidelity of implementation strategy: Educational meetings, Part 4	What will be measured: Dose: Number of meetings that each healthcare provider attended. How will it be measured: Data collection will be from healthcare providers on the ground.	Mar 2025 - Feb 2026
Fidelity of implementation strategy: Educational meetings, Part 5	What will be measured: Action: Content (topics)/style (lecture, didactic) of educational meetings How will it be measured: Data collection will be from healthcare providers on the ground.	Mar 2025 - Feb 2026

Collaborators and Investigators

• Sponsor: Geriatric Education and Research Institute
• Collaborators: National Healthcare Group Polyclinics; SingHealth Polyclinics; National University Polyclinics
• Investigators: Principal Investigator: Grace Sum, PhD, Geriatric Education and Research Institute

Publications and helpful links

General Publications

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Study record dates

Study Major Dates

• Study Start (Estimated): March 1, 2025
• Primary Completion (Estimated): February 28, 2026
• Study Completion (Estimated): February 28, 2026

Study Registration Dates

• First Submitted: December 11, 2024
• First Submitted That Met QC Criteria: December 22, 2024
• First Posted (Actual): March 25, 2025

Study Record Updates

• Last Update Posted (Actual): March 25, 2025
• Last Update Submitted That Met QC Criteria: December 22, 2024
• Last Verified: December 1, 2024

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Pathologic Processes; Frailty
• Other Study ID Numbers: GERI1637

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: The information will not be shared due to confidentiality.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No