Authors: (including presenting author): :
Chan YK(1), Chan SM(1), Chan TT(1), Au-Yeung WM(1), Lam KF(1), Wong YF(1), Kong SM(1), Yeung FL(1), Mok HY(1), Yuen CY(1), Lam FY(1), Wong YW(1), Ma CL(1), Wu SC(1), Tang YS(1), Ho WH(1), Chiang SC(1), Wong BC(1), Hung CB(1), Cheng SYR(1), Ng YS(1)
Affiliation: :
(1) Department of Family Medicine and Primary Health Care, NTWC
Keyword 1: :
Social prescribing
Keyword 2: :
Medical–social collaboration
Keyword 3: :
Integrated care
Keyword 4: :
Healthy ageing
Keyword 5: :
Care coordination
Keyword 6: :
Primary care sustainability
Introduction: :
People attending Family Medicine Out-patient (FMOP) services increasingly present with needs driven by social determinants of health, social disconnection, functional decline and caregiving transitions. These needs contribute to repeated attendance and poor continuity of care, yet are often insufficiently addressed within time-limited consultations. Social prescribing, embedded within an integrated medical–social framework, links primary care with community resources to support healthy ageing through coordinated, team-based care.
Objectives: :
To design, implement and evaluate an integrated social prescribing model in HA primary care that operationalises doctor- and nurse-initiated identification, with nurse-anchored care coordination and case management, through collaboration across FMOP services, Patient Resource Centres (PRCs) and community partners, strengthening access, continuity, safeguarding and governance for groups at risk of ageing-related social vulnerabilities.
Methodology: :
A pilot framework was implemented across NTWC FMOP services and PRCs, aligned with WHO social prescribing principles and HA workflows. Doctors and nurses conducted structured biopsychosocial assessments and co-developed personalised action plans with individuals and/or caregivers, then initiated referrals via a standardised pathway. Nurses acted as care coordinators and case managers, maintaining continuity, monitoring functional and caregiving risks, and liaising with PRC link workers for follow-up and escalation. PRC link workers coordinated access to mapped community resources and maintained the social intervention domain. Safeguarding followed predefined escalation pathways, with nurses and link workers triggering escalation and doctors providing clinical oversight. Shared documentation and monthly case discussions supported governance.
Result & Outcome: :
Between May and December 2025, 289 referrals were made. A 95% successful contact rate demonstrated timely access and assessment of needs. 92% of cases proceeded to receive active or completed social intervention, with 54% achieved case closure and 46% under active follow-up. Needs mainly involved caregiving stress, social isolation or functional constraints affecting healthy ageing and mental wellbeing. All received appropriate social interventions matched with their needs. All high-risk cases were managed through safeguarding pathways. Before implementation, an older woman caring for her wheelchair-bound post-stroke son developed dementia, leading to mutual caregiving breakdown and repeated FMOP attendance. Following PRC-coordinated intervention with nursing management and medical oversight, both were linked to caregiver support, respite and accessible community services, and lead to fewer FMOP attendances. This pilot focuses on service implementation and process outcomes to demonstrate feasibility and system readiness, and showed initial success in tackling social needs. Further evaluation on adoption, sustainability, patient- and caregiver-reported outcomes and service utilisation impact will be performed in the future.
