• According to the Hospital Authority, the unplanned readmission rate increased from 7% to 9.6% from the year 2000 to 2007. It has been commonly found that the unplanned readmission is caused by inadequate medical management or rehabilitation prior to discharge, social problems, diet management and deterioration of clinical status.

    In response to the need of the post-discharged elderly, the Salvation Army, Queen Elizabeth Hospital and Hong Kong Polytechnic University collaborate with 7 non-government organization (NGO) units to initiate a 28-day care model for supporting the elderly upon being discharged and catering for their needs. The Omaha System which has been used widely in the United States since 1975, will be the framework for our project in case assessment and intervention.

    This two-year pilot project is funded by The Hong Kong Jockey Club Charities Trust as one of the community projects under CADENZA: A Jockey Club Initiative for Seniors. A randomized controlledtrial will be carried out to examine the effects of health-social partnership transitional care model (HSP-TCM) on discharged elderly.
    Project Period
    May 2008 - July 2010
    Expected Results
    (1) An innovative and sustainable locally based transitional care model will be developed to support the discharged elderly in the community;
    (2) This seamless care intervention is essential in reducing the unplanned readmission rate of the discharged elderly patients.

      HSPTCM: Sharing Session cum Volunteer Appreciation Ceremony (31/7/2009)
    - Poster
      Newsletter ( 1, 2, 3 )

    The Salvation Army CADENZA Community
    Project:Health-social Partnership Transitional
    Care Model for Post-discharged Elderly
    • Address:

    • Shop D, G/F, Prosperous Garden, 3 Public SquareStreet, Yaumatei, Kowloon
      2782 1334   Fax: 2782 66453
      This email address is being protected from spambots. You need JavaScript enabled to view it.
    Office Hours:
    Mon-Sat 9:00am - 12:30pm; 1:30pm - 5:00pm

  • Objectives

    • (1) To assist the elderly in strengthening their physical, psychological and social aspects so as to enhance their self-efficacy upon being discharged and to reduce the unplanned re-admission rate of the elderly eventually;
    • (2) To develop a health and social interface transitional care delivery model that enhances the quality of care provided to the post discharged elderly.

    Service Content & Service Flow


    For more details, please refer to the Chinese version.