A Clinical Integrated Care (cic) Model Incorporating
Comprehensive Needs Assessment And Longitudinal
Clinical Integration In Hong Kong:
Author Block: PUN Kingsley Hiu Yeung1,2
, Chi Man, Kenny
CHUI, PhD(CUHK), MScCG, MScDS, MASSM, BSW(Hons)3,2
,
Florence Kwai Ying Ho2
, Timothy CY Kwok1,2
.
1Department of Medicine & Therapeutics, The Chinese
University of Hong Kong, Hong Kong, Hong Kong, 2
Jockey
Club Centre for Positive Ageing, Hong Kong, Hong Kong,
3Faculty of Medicine, The Chinese University of Hong Kong,
Hong Kong, Hong Kong.
Abstract:
Background: Hong Kong facing serious aging population
with people with dementia (PwD). Despite existing medicalsocial collaboration initiatives, the current care landscape
remains fragmented. Clinical assessments are often treated as
isolated, one-off clinical events within hospital system that fail
to dynamically inform long-term care plans or decisionmaking. This disconnect results in suboptimal resource
allocation and increased caring burden, creating urgent needs
for cohesive model that operationalizes clinical data and
comprehensive dementia needs assessments (DNAs) into
actionable, continuous care management.
Methods: This study proposes a novel CIC framework with
care suggestions tailored for urban healthcare systems. The
model implements a structured integration of clinical
assessment to capture multi-dimensional psychosocial and
clinical requirements and generate dementia care suggestions
by pre-approved care experts. For example, in physical health,
we monitor body weight changes and food intake records
integrated with depression scores and sleeping hygiene to
promote tailored healthy eating suggestions. These metrics
inform data-driven care pathways where an algorithm-based
protocol triggers automatic adjustments in social care
intensity and cognitive stimulation levels. Finally, a specialized
"Case/care Navigation” is introduced to bridge the gap
between specialists and NGO providers by digital Integrated
Care Plan (ICP), ensuring execution of person-centred care
effectively in clinical recommendations covering PwD and
formal/informal care partners.
Results: People with dementia were not familiar with
presentation of needs and bring to another challenge
misunderstanding of their discomfort until hospitalization.
The DNAs system could alert the significant others for earlier
interventions to provide timely treatment with the particular
needs of the families supporting those with dementia. This
integrated model reduced unplanned admissions or clinic
visits by identifying clinical change earlier than current care.
Furthermore, by aligning care intensity with clinical severity
through DNAs & ICP, the model could optimize the costeffectiveness of healthcare resources and improve PwD
outcomes.
Conclusion: The proposed CIC model addresses the
"implementation gap" in dementia strategy. By embedding
rigorous clinical assessment and comprehensive needs
assessment into the fabric of daily care coordination, the
system can transition from reactive, crisis-based care to a
proactive, patient-centered ecosystem. This framework offers
a scalable solution for cities facing similar demographic
challenges.