Authors (including presenting author) :
KAM KW(2); HUNG CB(1); NG YS(1); NG KM(1); CHANG TT(1); WONG BC(1); CHENG SM(2); ZHANG SW(2); CHENG YS(2); AU YEUNG TL(2); CHAN WT(2); KUNG KM(2); LAU AY(2)
Affiliation :
(1)FM & PHC, NTWC (2)PRC, NTWC
Keyword 1: :
Social Determinants of Health
Keyword 2: :
Medical Social Collaboration
Keyword 3: :
Primary Healthcare
Keyword 4: :
Patient Resource Centre
Keyword 5: :
Step care Model
Introduction :
While Social Determinants of Health (SDoH) are critical drivers of patient outcomes, Family Medicine Outpatient (FMOP) clinics often lack the structured capacity to address them. This pilot project, based in the New Territories West Cluster, was designed to test a new model where social workers are integrated into the FMOP services to systematically identify and mitigate SDoH through direct, tiered interventions, moving beyond simple referral to active case management and resource linkage.
Objectives :
To implement and evaluate the stepped-care intervention framework within primary healthcare setting. The model aimed to proactively identify unmet social needs during clinical encounters and provide stratified support, from resource navigation to intensive, individualized casework, to improve health literacy, wellbeing, and connection to community assets.
Methodology :
Driven by a preliminary social needs assessment with patients and carers, and through Medical Social Collaboration platforms, the intervention was structured using a stepped-care model. A referral pathway was established from FMOP to the PRC via the Generic Case Referral System (GCRS). Interventions were stratified into three levels: primary (education booths and leaflet dissemination), secondary (eight thematic program domains: community healthcare resources, technology, green, arts and culture, physical activity, social support, mental wellbeing, and work/skills), and tertiary (individualized link-worker consultations). Effectiveness was measured using the WHO-5 Well-being Index, the Hong Kong Health Literacy Scale, and a service satisfaction survey.
Result & Outcome :
During implementation from April to December 2025, over 30,000 social prescription leaflets were disseminated, 64 patients and caregivers participated in eight structured group programs, and more than 400 patients received personalized link-worker support. Initial participant and carer feedback indicated self-reported improvements in key areas: enhanced awareness of community resources, increased health literacy, and greater perceived wellbeing. The high uptake of personalized link-worker support highlights a strong demand for dedicated social work intervention within the clinical setting. This pilot demonstrates that embedding social workers in primary healthcare with a clear, tiered intervention protocol can effectively operationalize the addressing of SDoH. It provides a replicable framework for using social work expertise to strengthen the health-social care interface, proactively reduce social risk, and build a more responsive and holistic primary care system.
