hronic obstructive pulmonary disease (COPD) consistently poses a challenge to public healthcare due to its high hospitalisation rate. In January 2009, the Respiratory Collaborative Care Team was established in North District Hospital (NDH) to meet the impending surge in service demand. Taking a comprehensive approach, the Team transcends boundaries, and relies on cooperation across disciplines and between hospital and the community, to develop a Hospital at Home programme.

The Team emphasises cross-boundary collaboration of different healthcare disciplines to support early hospital discharge of patients and self-care at home. In nurturing a skilled healthcare workforce, training on how to manage patients is given to community nurses and other hospital staff. Apart from the opportunity to acquire new knowledge and skills, nurses and allied health staff take part in clinical decision-making, share their experience and give suggestions to doctors for improvement.

Through mutual support and learning, team members empower patients with disease self-management skills, provide them with crisis management packs and pay them timely home visits. Members also coach volunteers tending to elderly patients so that patients can be further supported in the community.

With patients' confidence in self-care restored, the hospitalisation rate of COPD patients in NDH has decreased accordingly. The model of the Respiratory Collaborative Care Team has been shared with hospitals in the New Territories East Cluster and other clusters to further develop new approaches to meet the demands of patients and the community.