Telehealth-Supported Discharge Programme for Frail Older Adults

Frailty is one of the most common geriatric syndromes among older adults, and manifests as three or more of these symptoms: weight loss, fatigue, weakness, slow walking speed (\<1.0m/s), and low physical activity. Characterized by multisystem physiological decline, frail older adults are at an increased risk for illnesses and poor psychosocial well-being. Older adults with frailty are also more susceptible to hospitalization and adverse outcomes following discharge. Known as the "critical period" after hospital discharge, these individuals are at risk for unplanned emergency department visits and hospital readmissions. Further, frail older adults often experience prolonged recovery periods following hospital discharge, and may also be more sedentary, which can lead to further functional decline. Existing evidence emphasize the need for tailored interventions to support frail older adults and address their complex, multifaceted physical and mental health needs during their transition from hospital to home. This pilot study addresses gaps in the literature by introducing a structured telehealth discharge support programme tailored to community-dwelling older adults with frailty to improve physical and mental health outcomes, reduce healthcare utilization, and enhance self-management and functional recovery. To facilitate innovation in transitional care, the programme incorporates remote health monitoring tools such as home-based gerontechnology (e.g., activity sensors) and pedometers to support physical activity and recovery.