he Community Health Call Centre is a perfect example of a community-based service model to help high-risk elderly patients stay healthy after discharge from hospital.

Formerly the Telephone Nursing Consultation Service started in the Hong Kong East Cluster in 2003, the Community Health Call Centre Team has been providing an integrated comprehensive support service through a world-class hi-tech and hi-touch proactive tracking telephone support system. More than 15,000 discharged high-risk elderly patients have benefitted from the Team's support since then.

The telephone support system is backed up by clinicians, nurses, information technology professionals, statisticians and ambulatory clinics in the HA, as well as non-governmental organisations and private doctors. This one-stop service bridges service gaps, monitors the situation of patients, provides timely interventions and referrals, and empowers patients and their caregivers to undertake self-management at home.

Three well designed evaluation studies have been conducted to find out whether the system met its objectives in detecting problems of patients at the earliest stage and reducing recurrent and unnecessary hospitalisation. A massive 25-50% drop in hospital utilisation and a decline in mortality have been consistently observed. In view of the encouraging results and positive feedback from patients, the system will be extended to eventually cover all seven clusters in the HA in the coming two years. There are also plans to expand the programme to benefit other patient groups.

The telephone support system makes full use of information technology.