Building a Medical-Social Collaboration Platform to Ease the Stress of End-of-Life Carers
Building a Medical-Social Collaboration Platform to Ease the Stress of End-of-Life Carers
The source text is in Chinese. This English version is for reference only. In case of any discrepancy between this English version and the Chinese version, the Chinese version shall prevail.
When our loved ones reach their end-of-life stage, our deepest hope is that they can spend their final days in familiar surroundings, with dignity and without suffering. However, in reality, why is it that a patient’s discharge from the hospital often marks the beginning of a new set of challenges? This common predicament reveals the long-standing invisible divide between Hong Kong’s healthcare and social welfare services.
The issue of continuity in end-of-life care has become a focal point for evaluating the effectiveness of the entire medical-social system. A recent research report by the Our Hong Kong Foundation has highlighted the complexity of terminally ill patients’ holistic care plans, including physical, psychological, social, and spiritual needs. This has exposed the deeply rooted issue of fragmentation and a lack of information sharing between Hong Kong’s healthcare and social welfare services. Without a fundamental reshaping of the current collaboration mechanisms, this challenge will eventually affect every family in Hong Kong.
Holistic End-of-Life Care Is Vital
Hong Kong’s population aged 65 or above is projected to rise from 23.6% in 2025 to 33.1% in 2045. During the same period, the population aged 85 or older will more than double, increasing from 3.3% to 8.6%. As the number of patients suffering from terminal illnesses such as cancer continuing to grow, the pressure on healthcare and social services will intensify.
Terminally ill patients face not only physical pain but also psychological loneliness, social isolation, and a pressing need for assistance with daily living. According to the Jockey Club End-of-Life Community Care Project, over 70% of terminally ill patients receiving community care have high-intensity psychological and social needs, while nearly 80% require substantial practical support. To fulfil the majority of citizens’ wish to live out their final days peacefully in a familiar environment, end-of-life care should focus on holistic care.
However, in the current system, there are significant gaps in information flow between healthcare providers, social welfare organisations, and carers. Imagine a senior patient who has just been discharged from the hospital: their family is handed a stack of discharge records, but is unsure how to accurately communicate the patient’s complex care needs to social workers at a community centre. Similarly, social welfare organisations may wish to provide support but are unable to access up-to-date medical information about the patient. As a result, patients and carers are compelled to act as the sole bridge for information transfer. Any miscommunication can lead to mismatched services or even delays in treatment.
Furthermore, this lack of information flow prevents healthcare professionals from understanding the actual conditions of patients after discharge, undermining the precision and safety of treatment plans. Lacking real-time medical information about patients, elderly care homes and social welfare organisations often provide support disconnected from clinical needs. Meanwhile, exhausted carers, who are unable to obtain complete information, struggle to make appropriate care decisions, inadvertently adding to their burdens.
Breaking Down Barriers for Seamless Service Integration
To overcome these barriers, the key lies in information integration. It is recommended that relevant departments take the lead in establishing a medical-social collaboration platform that consolidates healthcare, social welfare, and caregiver resources. This platform would enable information sharing and service coordination. By integrating electronic medical records, social service records, and personal care plans from elderly care homes, and connecting seamlessly with the “eHealth+” system, healthcare professionals could access real-time updates on patients’ physical and mental conditions. Social welfare organisations could then adjust their services accordingly, and carers would be better equipped to make informed care decisions.
A core feature of this platform would be the creation of a centralised, real-time social services database. Inspiration can be drawn from Singapore’s long-standing Integrated Referral Management System (IRMS) and its upgraded version, BRIGHT, as well as local platform, such as St. James’ Settlement’s “656carer.com”. The platform should include electronic referral functions, enabling hospitals, clinics, and social welfare organisations to seamlessly hand over cases. More importantly, the platform should allow professionals and the public to check the real-time availability of various services (such as respite care and day care) instantly, replacing the current inefficient model of making individual phone enquiries. This would significantly reduce the stress on carers.
Looking ahead, the platform could also leverage artificial intelligence technology to drive data-driven resource allocation and policy formulation. By analysing data such as hospitalisation durations, mental health conditions, and service usage rates, relevant departments could accurately assess the effectiveness of end-of-life care services and optimise resource allocation. This would result in more targeted and effective policies.
The challenges of end-of-life care reflect the broader need for integration within Hong Kong’s healthcare and social welfare systems. Building a medical-social collaboration platform is not merely a technical upgrade, but a key step in fostering cross-sector collaboration and reshaping the culture of care. Only by transitioning from fragmentation to integration can we truly safeguard patients’ dignity and quality of life, alleviate the burdens on families and the healthcare system, and inject new momentum into Hong Kong’s medical-social service system.
The source text is in Chinese. This English version is for reference only. In case of any discrepancy between this English version and the Chinese version, the Chinese version shall prevail.
When our loved ones reach their end-of-life stage, our deepest hope is that they can spend their final days in familiar surroundings, with dignity and without suffering. However, in reality, why is it that a patient’s discharge from the hospital often marks the beginning of a new set of challenges? This common predicament reveals the long-standing invisible divide between Hong Kong’s healthcare and social welfare services.
The issue of continuity in end-of-life care has become a focal point for evaluating the effectiveness of the entire medical-social system. A recent research report by the Our Hong Kong Foundation has highlighted the complexity of terminally ill patients’ holistic care plans, including physical, psychological, social, and spiritual needs. This has exposed the deeply rooted issue of fragmentation and a lack of information sharing between Hong Kong’s healthcare and social welfare services. Without a fundamental reshaping of the current collaboration mechanisms, this challenge will eventually affect every family in Hong Kong.
Holistic End-of-Life Care Is Vital
Hong Kong’s population aged 65 or above is projected to rise from 23.6% in 2025 to 33.1% in 2045. During the same period, the population aged 85 or older will more than double, increasing from 3.3% to 8.6%. As the number of patients suffering from terminal illnesses such as cancer continuing to grow, the pressure on healthcare and social services will intensify.
Terminally ill patients face not only physical pain but also psychological loneliness, social isolation, and a pressing need for assistance with daily living. According to the Jockey Club End-of-Life Community Care Project, over 70% of terminally ill patients receiving community care have high-intensity psychological and social needs, while nearly 80% require substantial practical support. To fulfil the majority of citizens’ wish to live out their final days peacefully in a familiar environment, end-of-life care should focus on holistic care.
However, in the current system, there are significant gaps in information flow between healthcare providers, social welfare organisations, and carers. Imagine a senior patient who has just been discharged from the hospital: their family is handed a stack of discharge records, but is unsure how to accurately communicate the patient’s complex care needs to social workers at a community centre. Similarly, social welfare organisations may wish to provide support but are unable to access up-to-date medical information about the patient. As a result, patients and carers are compelled to act as the sole bridge for information transfer. Any miscommunication can lead to mismatched services or even delays in treatment.
Furthermore, this lack of information flow prevents healthcare professionals from understanding the actual conditions of patients after discharge, undermining the precision and safety of treatment plans. Lacking real-time medical information about patients, elderly care homes and social welfare organisations often provide support disconnected from clinical needs. Meanwhile, exhausted carers, who are unable to obtain complete information, struggle to make appropriate care decisions, inadvertently adding to their burdens.
Breaking Down Barriers for Seamless Service Integration
To overcome these barriers, the key lies in information integration. It is recommended that relevant departments take the lead in establishing a medical-social collaboration platform that consolidates healthcare, social welfare, and caregiver resources. This platform would enable information sharing and service coordination. By integrating electronic medical records, social service records, and personal care plans from elderly care homes, and connecting seamlessly with the “eHealth+” system, healthcare professionals could access real-time updates on patients’ physical and mental conditions. Social welfare organisations could then adjust their services accordingly, and carers would be better equipped to make informed care decisions.
A core feature of this platform would be the creation of a centralised, real-time social services database. Inspiration can be drawn from Singapore’s long-standing Integrated Referral Management System (IRMS) and its upgraded version, BRIGHT, as well as local platform, such as St. James’ Settlement’s “656carer.com”. The platform should include electronic referral functions, enabling hospitals, clinics, and social welfare organisations to seamlessly hand over cases. More importantly, the platform should allow professionals and the public to check the real-time availability of various services (such as respite care and day care) instantly, replacing the current inefficient model of making individual phone enquiries. This would significantly reduce the stress on carers.
Looking ahead, the platform could also leverage artificial intelligence technology to drive data-driven resource allocation and policy formulation. By analysing data such as hospitalisation durations, mental health conditions, and service usage rates, relevant departments could accurately assess the effectiveness of end-of-life care services and optimise resource allocation. This would result in more targeted and effective policies.
The challenges of end-of-life care reflect the broader need for integration within Hong Kong’s healthcare and social welfare systems. Building a medical-social collaboration platform is not merely a technical upgrade, but a key step in fostering cross-sector collaboration and reshaping the culture of care. Only by transitioning from fragmentation to integration can we truly safeguard patients’ dignity and quality of life, alleviate the burdens on families and the healthcare system, and inject new momentum into Hong Kong’s medical-social service system.
