Hospital-community continuity of care in fragile patients before and after major surgery–an exploratory case control study

Background: Frailty is a multifaceted geriatric syndrome that heightens vulnerability to adverse health outcomes, especially in surgical settings. While preoperative geriatric assessments have shown promise in mitigating these risks, their translation into actionable care plans across hospital and community settings remains a challenge. The fragmentation in Israel’s healthcare system further exacerbates this issue, leaving gaps in care continuity that impact recovery outcomes for frail patients. This study evaluates a structured continuity-of-care model designed to bridge hospital-community gaps by directly transferring geriatric assessment findings to primary care physicians (PCPs). The impact on functional, mental, and physical outcomes, as well as PCP engagement, was examined. Methods: A prospective observational study with a parallel-group design was conducted among 161 elective surgery patients aged 87 and older, or 70–86 with high frailty risk scores. Frailty was measured using the Assuta Frailty Score (AFS), based on the validated Multidimensional Frailty Score (MFS). Intervention group patients received a nurse-led geriatric assessment and structured transmission of results to their PCPs, while control patients self-delivered assessment findings. Outcomes were measured three months post-surgery using the Barthel Index, Lawton IADL, and SF-12. Results: Intervention group patients exhibited a smaller decline in ADL scores (-2.10 vs. -6.03, p = 0.14) and improved IADL outcomes (-0.54 vs. -2.09, p = 0.13). Self-reported general health also improved more in the intervention group (+ 3.89 vs. +2.47, p = 0.15). Assessment results were systematically transferred to PCPs in the intervention group, while only 35% of control patients reported doing so. Patient-reported PCP engagement with results was low in both groups (16% vs. 11%; p = 0.298). Conclusions: A structured continuity-of-care model shows potential for improving postoperative recovery among frail patients by enhancing communication between hospitals and community care providers. However, systemic barriers, including low PCP engagement and fragmented healthcare coordination, limit its full impact. Future studies should develop and evaluate integrated care models with structured communication, emotional support, and digital tools, using robust designs such as randomized or cluster trials.