Integrating Medical and Social Support for Elderly in Hong Kong - System and Technology Enabled Service Innovations.

Hong Kong is proud of its population's long life expectancy, but rapid population ageing is one of its greatest challenges. The Hospital Authority (HA) is the largest healthcare organization in Hong Kong. To cope with the challenges, HA has formulated the "Strategic Service Framework for Elderly Patients", emphasizing the development of multidisciplinary integrated elderly services, patients and caregivers; engagement, and enhancing collaboration with community partners. Over the past few years. HA has innovated and re-engineered various service models to provide appropriate care based on the stratified needs of individual elderly patients. We have adopted an integrated case management approach to cater for the multi-faceted needs of high risk elderly, enhanced chronic disease management and improved support for self-care. Information technology has played a significant role in transforming the service model. Evaluation of the new programmers showed encouraging results in reduction of unnecessary hospitalizations, improvements in health outcomes and patient empowerment.