Initiated in February 2017, “Dementia Community Support Scheme” (DCSS) is a two-year pilot scheme launched by the Food and Health Bureau (FHB), in collaboration with the Hospital Authority (HA) and the Social Welfare Department (SWD). The pilot scheme was funded by the Community Care Fund and implemented from February 2017 to January 2019, with an ultimate goal of utilising collaboration of social and medical support at primary care level and specialist care to form an integrated support network for the patients in the long run. Four HA clusters and 20 District Elderly Community Centres1 (DECCs) participated in the Pilot Scheme to provide support services to elderly persons with mild or moderate dementia and their carers in the community through a “medical-social collaboration” model so as to enhance their functional level and quality of life, and relieve carers’ burden. 
Under DCSS, elderly persons with mild or moderate dementia and their carers are arranged to attend structured intervention programmes based on an individual Integrated Care Plan (ICP) at the DECCs, with an aim to delay their functional and cognitive decline. DCSS also aims at enhancing the capacity and expertise of the staff of NGOs at the community level in the provision of dementia support services to elderly persons, so that in the long run, reliance on HA specialist services may be alleviated when those suffering from early dementia and their carers can acquire relevant support services in the community. Over a two year period, the pilot scheme served over 2000 elderly persons with dementia and their carers. The feedback from the participating patients and their carers was overall positive; the evaluation study conducted by Sau Po Centre on Ageing of the University of Hong Kong also suggests generally effective implementation.
From February 2019 onwards, Dementia Community Support Scheme is regularised and extended to all 41 DECCs and seven HA clusters in the territory. The 20 DECCs and four HA clusters which participated in the pilot scheme would continue to provide support services and the other 21 DECCs and three HA clusters join DCSS from May 2019 onwards.
 

Community geriatric assessment services was established in 1994 by HA to better serve elderly from residential care 
homes of the elderly (RCHE), who are high volume users of HA services. CGAS vision of seamless care was to provide timely geriatric management together with social sector partners to enhance care quality in the community. Service scope started with outreach geriatric specialist clinics and nurse-led care improvement initiatives, rehabilitation and assessment for central infirmary waiting list. Following SARS in 2003, expert recommendations endorsed by government led to the CGAS VMO scheme aimed to reduce infectious outbreaks in RCHEs and to curb surges in hospitalization. 
Present CGAS services have evolved with enriched partnerships to include end of life care for RCHE residents, pharmacist-led medication reconciliation and integrated nursing model with community nursing services. 
The future of CGAS contemplates our service model to meet rising demand arising from increasing RCHE places with increased care complexity expected to parallel ageing demographics in Hong Kong. New enhanced CGAS service models, especially in mega-homes will reduce demand for hospital beds. On-site end of life care and rehabilitation should be standards in care with structured medical social partnerships and quality monitoring. In addition, the wise use of IT, big data and telemedicine add to exciting prospects. To navigate future challenges, CGAS teams can learn from 25 years of lessons in teamwork, compassionate care and innovation.
 

Our experience developing the Comprehensive Care Physician (CCP) program within the Section of Hospital Medicine at the University of Chicago has illustrated the value of relational continuity in the care of patients with complex medical needs. For patients with increased risk of hospitalization and who are willing to find a new primary care physician, the program suggests significant value in having a single provider care for patients in both the inpatient and outpatient setting. Additional opportunities to leverage patient-provider and provider-provider relationships remain for patients at lower risk of hospitalization and those with established primary care relationships. 

Traditional United States hospitalist models are based upon schedules where providers work intermittent, intense shifts, typically working 7 days in the hospital followed by 7 days of respite time. These schedules lead to frequent hospitalist-hospitalist handoffs within a patient’s hospitalization. In addition, the large number of hospitalists at many institutions and their intermittent schedules makes it difficult to establish relationships between inpatient and outpatient providers.

To better leverage the value of patient-provider continuity within prolonged hospitalizations and provider-provider relationships for hospitalists and outpatient clinicians who frequently admit patients to the hospital, we propose a new model for hospitalist care. Under the Rounder Model, the work of hospitalists typically performed over intense 7-day periods will be re-allocated across more weekdays, thereby enabling hospitalists to sustainably work more days per year. This reorganization of hospitalist work will enable greater patient-provider continuity within hospitalizations by enabling individual hospitalists to direct the care of a patient throughout his or her entire hospitalization. The Rounder Model will also enable pairing of individual hospitalists or small groups of hospitalists to outpatient providers to promote provider-provider relationships across the inpatient and outpatient domain as well as patient-hospitalist relationships for patients from paired groups who are frequently hospitalized themselves.

We hypothesize that this reorganization of care will result in reduced length of stay and increased quality of care for hospitalized patients by leveraging relationships to promote smoother transitions of care. In addition, we hypothesize that this model will serve as a more sustainable long-term career option for the hospitalist workforce.

Established in 1965, New Life Psychiatric Rehabilitation Association is a leading non-governmental organization specializing in mental health serving around 15,000 people in recovery (PIR) of mental illness and their families, as well as 43,000 general public in mental health education annually by 70 service units/ projects and over 20 social enterprises. Our Association pioneered the first Integrated Community Centre for Mental Wellness (ICCMW), The Wellness Centre (TWC) at Tin Shui Wai in 2009. From October 2010 onwards, service points extended to Sham Shui Po, Yau Tsim Mong, Sha Tin, Kwai Chung, Tuen Mun and Islands Districts. In 2015, our Association moved forward from recovery-oriented service to promote well-being for all. We integrate 330 (physical, psychosocial and transcendental well-being) into daily life.
Three-tier service model ranging from primary (community well-being and public education); secondary (early identification and intervention); to tertiary intervention (person-centered services) is adopted in The Wellness Centres (TWCs). Selected highlights at each level would be shared. At the primary level, TWCs promote well-being to the public on understanding of mental health; advocating for anti-stigma and collaborating with district partners to build an inclusive society by organizing exhibitions, talks and activities in the community. “330@ New So Uk Estate”, a three-year project funded by the Community Investment and Inclusion Fund (CIIF), was launched in 2016 to enhance the community well-being, facilitate the accumulation of social capital and provide neighborhood support to residents of the re-developed So Uk Estate. At the secondary level, TWCs worked closely with the Hospital Authority, Social Welfare Department and community partners to provide proactive, comprehensive and intensive casework support services to people suspected of having mental health problems. Last but not least, at the tertiary level, our professional staff team, consisting of clinical psychologists, social workers, occupational therapists and psychiatric nurses, provides casework counselling and outreaching home visits, helping PIR and their family members to cope with their mental health and life challenges, actualizing self-directive in their journey of recovery and leading to a fulfilling life in the community.