Authors: (including presenting author): :
Chan YKJ(1), Wong MYM(2), Wan MC(3), Woo WSS(1), Wong CW(2), Lee ST(1), Po MYY(4), Lam YF(1), Siu TS(3), Cheng PL(3), Ho WH(3), Chan YK(1), Yu CS(1), Szeto SM(1), Lui KK(1), Cheung MY(1), Chung KY(1), Chan WY(1), Hung TK(5), Lau KW(5), Lee CM(3), Kwan WY(3), Kwong SW(3), Cheung Y(3), Wong YYR (6)(7), Fung WHH(7)
Affiliation: :
(1)Department of Medicine, Pamela Youde Nethersole Eastern Hospital, (2)Primary and Community Health Care, Hong Kong East Cluster, (3)Department of Medicine and Geriatrics, Ruttonjee & Tang Shiu Kin Hospitals, (4)Community Health Services, Hong Kong East Cluster, (5)Cluster Statistics Office, Hong Kong East Cluster, (6)Community & Patient Resource Department, Pamela Youde Nethersole Eastern Hospital, (7)Community Services, Hong Kong East Cluster
Keyword 1: :
Hidden High-Risk elderly
Keyword 2: :
Medical Social Collaboration
Keyword 3: :
Data Matching Model
Keyword 4: :
Community Support
Introduction: :
HRE are those with unmet needs and unknown to social welfare services, or not identified as “Red-Alerted” leading to missing opportunities for timely intervention. This leads to unplanned hospitalization, premature institutionalization, higher healthcare costs and social tragedies involving isolated elders. Currently, Hospital Authority (HA) and Social Welfare Department (SWD) own separated databases to identify HRE without formal exchange system. The HKEC HRE Matching Model Trial Run aimed at putting the concept of Data-Driven Care Model into practice, testing a workflow of data matching to facilitate early identification and timely social intervention in the community.
Objectives: :
To test the feasibility and workflow of a data matching system between HKEC and SWD for the identification of HRE using HARRPE and clinical referrals as screening tools, triage of cases and direct referral for timely social intervention rendered by District Elderly Community Centres (DECCs).
Methodology: :
A multidisciplinary Task Force comprising PYNEH and RTSKH Geriatric teams, HKEC Community Services, SWD, and 6 DECCs conducted a trial from March to May 2025. A two-tiers screening process was adopted: (1) screening medically weak elderly using HARRPE (≥0.2) or clinical referral; (2) screening social frailty through manual matching with SWD’s databases. Identified HRE were recruited to DECCs for essential services.
Result & Outcome: :
From 13,226 hospital admissions, 3,221 medically weak elderly patients were identified; 71 were further assessed as both medically weak and socially frail. After matching with SWD, 40 HRE (56.3% of socially frail cases) were identified as “hidden” and referred to DECCs. The model demonstrated data verification, early identification of additional “hidden” HRE previously not under SWD’s network, and accurate referral to DECCs. The result leads to a breakthrough in Community care with expedited roll-out of “Vulnerable Carers Database” since July 2025. An Automated HRE Matching Model using an elderly service enquiry portal was subsequently developed by SWD in HKEC, signifying a policy change to advocate data-driven care between SWD and HA, enabling timely social intervention and optimization of resource allocation for HRE.
