Symposium 10 - Medical Social Collaboration

The Siu Lam Integrated Rehabilitation Services Complex (SLIRSC), established by Hong Kong's Social Welfare Department (SWD) and situated in Tuen Mun, is the city's largest purpose-built rehabilitation facility, providing 1,150 residential placements and 560 day training places for individuals with mental, intellectual, and physical disabilities. Managed by three NGOs-SAHK, Tung Wah Group of Hospitals, and New Life Psychiatric Rehabilitation Association-it fulfills a 2013 policy initiative to expand care for disabled persons. As of March 2025, SLIRSC serves 751 residents. A large proportion of the residents are elderly with multiple chronic conditions, requiring frequent follow-ups at SOPCs and GOPCs. Mobility issues further complicate transportation to clinics, while managing infections in a large residential environment poses additional risks. All these challenges call for a tailor-made Medical-Social Collaboration model.


Overseen by a Committee led by the Cluster Chief Executive of New Territories West Cluster of Hospital Authority and Assistant Director of SWD, this collaboration integrates health and social services with three goals: streamline care delivery, enhance quality, and improve efficiency. Key strategies include reserving clinic quotas for SLIRSC residents, enhancing telehealth for follow-ups at GOPCs and SOPCs, and establishing outbreak management protocols. These efforts have led to improved access to care and effective management of COVID-19 outbreaks. The model also focuses on staff training and specialised health interventions, such as successful MRSA decolonisation therapy, to enhance the quality of service. Medication management was also streamlined by electronic transfer of dispensing data, reducing errors and saving time.


The Medical-Social Collaboration model at SLIRSC emphasises partnerships between healthcare providers and social services to enhances access, care quality, and resource use for a complex population. Early outcomes are encouraging, with continuous refinements and collaboration aiming to strengthen holistic care in residential care homes in Hong Kong.

The Smart Hub (健康小屋) initiative represents a transformative approach to healthcare delivery in Hong Kong's remote and underserved areas. With approximately 15% of the North District population residing in these areas, traditional mobile clinics face significant challenges, including limited coverage, weather dependency, restricted drug supply, inefficient manpower use, and service disruptions due to COVID-19 pandemic.


The Smart Hub model leverages smart technology, telemedicine, and medico-social collaboration to overcome these barriers, aiming to improve healthcare access, efficiency, and patient empowerment. By establishing smart hubs in convenient locations within patients' neighborhoods, such as village houses, and equipping them with teleconsultation facilities, the initiative integrates technology with community support, collaborating with NGOs to provide on-site assistance and patient empowerment activities.


The target population primarily includes chronic disease patients who require regular follow-ups but face significant challenges due to their remote locations. The care delivery process is designed to be patient-centered, incorporating teleconsultations, drug delivery, and annual face-to-face consultations, complemented by on-site support and patient empowerment programs. Since its pilot launch in February 2023, the Smart Hub has expanded to over 50 sites, serving more than 300 patients and delivering over 1,000 teleconsultations with high levels of patient satisfaction. Feedback from participants has been overwhelmingly positive, with many highlighting the convenience of accessing healthcare services close to home and the reduced burden on caregivers, who no longer need to take time off work to accompany patients to distant clinics.


Looking ahead, the initiative plans to expand further, covering more villages and patients across the North District and outlying islands. This innovative model demonstrates the potential of integrating technology and community collaboration to enhance healthcare access, improve patient outcomes, and address the unique challenges of delivering care in remote and underserved areas.

The breast cancer incidence in Hong Kong has been rising for the past 30 years. In 2021, women in Hong Kong have a 1 in 13 lifetime risk of developing invasive breast cancer (BC) before the age of 75a. The good news is, BC death rates have remained consistently low, but this also means our SOPD is currently taking care of many BC survivors who live long but endure a spectrum of physical, psychological and functional sequel of the disease and its treatment, which we are unable to address fully in our busy clinics.
The Hong Kong Cancer Strategy has set out the direction to improve cancer survivorship care in 2019. KWC Oncology, hand-in-hand with KWC Community Health Care Office, and our community partners, have responded with several pilot projects aimed at establishing sustainable medical-social service models to care for cancer survivors in the community. 
The District Health Centre (DHC) - KWC Breast Cancer Survivorship Program was piloted in 2021 with Sham Shui Po DHC to address rehabilitation needs and provide psychosocial support for BC survivors. The program structure, bi-directional referral mechanisms, methods of staff training and patient promulgation, were original designs. Expanding in scale ever since, the program is currently available in all 3 DHCs in Kowloon West, and can benefit all non-metastatic BC survivors younger than 70 years-old who have follow up at oncology and surgery SOPDs in KWC. Over 200 patients had been referred to these program, with more than half eventually enrolled and providing encouraging feedback.
The "CONNECT": KWC-HKMA Hospital-to-Community Cancer Survivorship Program was piloted in February 2025, in which long term BC survivors are being referred to community doctors, who received structured training from KWC oncologists, for regular follow-up. The preparatory work of this project included a survey on perceptions of local community doctors in providing care for cancer survivors. Among the 109 practitioners, 63% were interested in providing shared-care to cancer survivors, and top five facilitators for developing a shared-care model were identified.
In this presentation, the hurdles in piloting the DHC Survivorship Program and the CONNECT Program, the current state of affairs, patient feedback, details of the aforementioned survey, and our vision that fuels these efforts, will be shared.