The Siu Lam Integrated Rehabilitation Services Complex (SLIRSC) is a newly established rehabilitation facility developed by the Social Welfare Department (SWD) on the former site of Siu Lam Hospital in Tuen Mun. It was created as part of the Chief Executive’s 2013 Policy Address initiatives for increasing subvented day and residential care placements for persons with disabilities.1 As the largest purpose-built rehabilitation facility in Hong Kong, the SLIRSC provides 1150 residential placements and 560 day-training placements for individuals in mental recovery, as well as those with intellectual and/or physical disabilities. It includes five residential care homes for persons with disabilities, which are operated by three non-governmental organisations (NGOs), namely, SAHK, Tung Wah Group of Hospitals, and New Life Psychiatric Rehabilitation Association.

The SLIRSC accommodates a large population of relatively advanced-age residents with multiple co-morbidities. As of 31 August 2024, the SLIRSC houses 567 residents, approximately one-third of whom are aged ≥60 years. Many residents require follow-up by various specialties, including 329 (58%) who require medical follow-up and 421 (74%) who require psychiatric follow-up. Despite its scenic natural landscape, the relatively remote location of the SLIRSC creates challenges when transporting residents to hospitals for medical care. Moreover, a substantial proportion of residents display mobility problems—more than one-fifth (21%) are either chairbound or bedbound. Some residents experience difficulty in adjusting to unfamiliar environments while they receive medical care outside the facility, leading to a need for more intensive care and supervision. These challenges emphasise the importance of an innovative medical-social collaboration model tailored to the unique requirements of the SLIRSC.

The World Health Organization has suggested that an integrated health service model, based on strong primary care and public health functions, can improve the distribution of health outcomes, enhance well-being, and increase quality of life.2 3 There is growing recognition of the need to integrate various health services to provide coordinated, patient-centred care.4 This integration can improve care quality, expand patient access to services, and reduce wait times for outpatient appointments.5 Notably, medical-social collaboration is one of the core strategies outlined in the World Health Organization Framework on integrated, people-centred health services.2 Collaboration is defined in various ways throughout the literature. Generally, it represents processes intended to improve efficiency and quality via synergistic combinations of resources and expertise from different organisations.6 7 This approach reduces duplication and facilitates the sharing of expertise and resources, enabling organisations to explore solutions beyond the limitations of their own perspectives.8 Medical-social collaboration is especially beneficial for populations with needs encompassing physical, mental, and social domains.9 Partnerships between the Hospital Authority (HA) and local NGOs are not new. As early as 2012, integrated medical and social support initiatives were already targeting and serving older adults in Hong Kong.10 Additional collaborative efforts include the Integrated Discharge Support Programme for high-risk older patients and the District Health Centres led by the Health Bureau.11 12

The Committee for Service Implementation of the SLIRSC was established in 2023. The Committee is led by Dr YC Wong, Cluster Chief Executive of the New Territories West Cluster (NTWC) of the HA and Ms Maggie Leung, Assistant Director (Rehabilitation and Medical Social Services) of the SWD. It consists of stakeholders from the HA, SWD, and NGOs, which provides strategic direction and guidance regarding medical-social collaboration and support for the SLIRSC. A medical-social collaboration task force for the SLIRSC was created under the Committee to serve as a working platform for key stakeholders and facilitate collaboration among parties. Our medical-social collaboration model has three primary objectives: (1) streamline delivery of care, (2) enhance quality of care and services, and (3) improve backend efficiency.

Considering the relatively remote location of the SLIRSC, our medical-social collaboration strives to facilitate on-site management, minimising the need for patient transport and admissions. To provide additional medical support, Yan Oi General Out-patient Clinic (GOPC), the clinic closest to the SLIRSC, has reserved appointment times for SLIRSC residents to manage episodic and chronic illnesses. The SLIRSC can make prior arrangements with the Yan Oi GOPC. Unused appointment times are released back to the general pool. The utilisation of these reserved appointment times increased from 2% in January 2024 to 24% in July 2024.

Clustering follow-up appointments for residents through telehealth can mitigate distance barriers, conserve manpower, and reduce the time required for travel and transport.13 14 Specific telehealth workflows have been established by the Yan Oi GOPC and Tuen Mun Mental Health Centre, the psychiatric specialist out-patient clinic of Castle Peak Hospital, to facilitate case selection and delivery of care via telehealth. Telehealth has been used in the treatment of minor ailments, protocol-driven management, and follow-up of stable chronic illnesses. It is also utilised for initial case triage to reduce unnecessary attendance at the accident and emergency departments.

Outbreak containment is important in any large-scale residential complex.15 The NTWC has collaborated with NGO operators to develop specific management guidelines for infectious disease outbreaks. Close surveillance is performed by the SLIRSC and NTWC, enabling early detection of infectious disease clusters and triggering necessary responses. Several communication platforms have been established between the NTWC and SLIRSC. Timely infection control guidance is provided by NTWC infection control team; face-to-face or telehealth consultations are arranged based on disease severity and symptomatology. In the event of a large-scale outbreak, the NTWC coordinates necessary medical support, admissions, and bed assignments in wards. This workflow has been activated twice (July 2024 and August 2024) to manage two coronavirus disease 2019 outbreaks, both of which were contained within a small area and for a limited duration.

A substantial number of SLIRSC residents require specialised nursing care. Our medical-social collaboration enhances the quality of care through the train-the-trainer programmes for new staff. These programmes focus on specialised nursing care, including management of the unique needs of residents with mental and intellectual disabilities and stoma care. Physiotherapists and occupational therapists from the NTWC also provide services through a hybrid mode, assisting local allied health professionals in delivering specialised on-site rehabilitation programmes.

Due to the extensive impact of methicillin-resistant Staphylococcus aureus (MRSA) colonisation on the daily operations of the SLIRSC and provision of rehabilitation to residents, the NTWC has arranged MRSA decolonisation therapy for the SLIRSC. Prior training was provided to SLIRSC staff to enhance compliance. The programme began in June 2024 and the first group showed a success rate of 76% (16 of 21 MRSA carriers completed decolonisation and tested negative for MRSA upon re-evaluation). Successful cases will be de-labelled in the HA system. This training allows SLIRSC staff to continue on-site MRSA decolonisation therapy for carriers.

Increased efficiency is another primary goal of our collaboration. The SLIRSC is equipped with a state-of-the-art in-house medication management system. The NTWC facilitates the electronic transfer of dispensing data by supporting the input of dispensed medication information into their system. This system reduces administrative and medication errors, improves dispensing efficiency and medication safety, enhances productivity, and reduces the required manpower, saving both time and costs. A dedicated telehealth workflow for the SLIRSC further increases efficiency in medication collection after telehealth consultations, shortening wait times and conserving manpower within the SLIRSC.

As the largest purpose-built rehabilitation facility in Hong Kong, the SLIRSC offers a unique opportunity to re-orient our service model for residential homes by strengthening local medical-social collaboration. Thus far, outcomes have been promising; continuous review with collaborative efforts will further refine our service model, with the aim of promoting holistic care for persons with disabilities.

All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

All authors have disclosed no conflicts of interest.

The authors thank the following individuals and parties for their contributions to this article:

1. Mr CC Law, Dr KM Cheng, Dr Jessica Wong and Mr WM Chung from Department of Psychiatry, Castle Peak Hospital;
2. Dr Steve Tso from Department of Psychiatry, Siu Lam Hospital;
3. Ms Mandy Mak from Department of Physiotherapy, Tuen Mun Hospital;
4. Ms Pauline Chu from Department of Pharmacy, Tuen Mun Hospital;
5. Ms Maggie Leung, Assistant Director (Rehabilitation and Medical Social Services) of Social Welfare Department;
6. SAHK;
7. Tung Wah Group of Hospitals; and
8. New Life Psychiatric Rehabilitation Association.

This editorial received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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