The rapidly aging population and extension of the longevity of terminally ill patients in Hong Kong may only result in deterioration of their quality of life if their need for adequate care could not be addressed. A growing demand for a paradigm shift from a heavy hospital-centric care to a care model supplemented with a community-based integrated care is also applied in Hong Kong. From 2022 onward, a home-based end-of-life service has commenced to support terminally ill patients and caregivers in Kowloon West Cluster. The collaboration between hospital and community partners imposes an intention to move from fragmented and disease‐oriented care to coordinated and holistic care. However, integrating care across different sectors, organizations and system interfaces to deliver person-centered care is a complex process influenced by a variety of enablers and barriers. Some studies pointed out the gap in the local existing collaboration and identified key factors that promote or impede successful integration of care across diverse settings internationally. Nevertheless, there is a lack of detailed information in Hong Kong about how the gap to be filled up from a rounded stakeholder perspective. A qualitative study was carried out to explore views and experience of key stakeholders including palliative care doctors, home care nurse, patients and caregivers, community care workers and medical social workers. Together with the experience of medical social collaboration in the past few years, we would like to take this opportunity to share our insights like the important role of a link person, two-tier communication and case stratification mechanism etc., and possible challenges from both our current experience and qualitative study so as to generate insight on refining current community care collaboration practice in the future.
