Health is one of the most important determining factors in the quality of life of our elders. The interface between medical and social care in the rehabilitation stage is hence a topic of immense significance. It is my privilege to be invited to share with you my thoughts on this key topic.

According to the findings of the thematic household survey conducted by the Census & Statistics Department in 2008, we are pleased to note that the overall health of our elderly population is good and that the overwhelming majority of our elders have expressed little difficulty in carrying out their daily activities such as meal preparation, ordinary housework, managing finance, managing medication, using the telephone, shopping and transportation.

As reflected in a recent study conducted by the Chinese University of Hong Kong, most of our elders prefer to age at home. This is very natural for the Chinese community. After all, there is no place like home. The elders can continue to enjoy the care and support of their families and neighbours while staying in the community. And the feeling that somehow they do belong in their own community and neighbourbood is very dear to the majority of our elders.

This preference of our elders to continue living at home provides the backdrop of the Government's policy to promote ageing in place, which is also a common approach adopted internationally. We believe that families and neighbours can play an important role in the care and support of our elders.

What does that mean to the various professionals, medical and social service providers as well as the Government? One very important point to bear in mind is that it is not enough to have a world-class medical care or social service provision standing on its own.

Medical and social elements have to break down the respective professional silos and integrate in the very community that the elders live in. The development of integrative initiatives underscores the increasing awareness of the need for better, seamless integration of medical and social care for elders.

Let me start by looking at the efforts of integration at elders' home. A successful ageing in place policy does not materialise in a vacuum. The integration of medical and social provision of care should start at home - in the community in which the elders reside.

The adequate provision of community care and support services is the key to enabling our elders to remain at home while ageing. In this connection, we have, in the past few years, enhanced our community care and support services for frail elders, and introduced new initiatives to support our elders to age in place. Let me elaborate on what the Government has done to translate these philosophies into practice.

Under our subsidised community care services for frail elders, the responsible social workers, together with healthcare professionals and para-medical professionals taking care of the elders, will tailor-make for each elder a set of systematic individual care plans. This is to ensure that the elders are provided with the most suitable care.

It is not uncommon for elderly patients to be re-admitted to hospitals or admitted to residential care homes for the elderly shortly after hospital discharge. A major reason for this is the deterioration of health conditions owing to the lack of family and/or social support during the rehabilitation stage.

The Government has been working closely with the Elderly Commission to reduce unplanned hospital re-admissions as well as premature or unnecessary institutionalisation of elders so as to realise the policy objective of promoting ageing in place.

To this end, the Government, in collaboration with the Hospital Authority, launched an integrated discharge support trial programme for elderly patients in March 2008 to provide one-stop support services to help elderly patients stay in the community after hospital discharge. To all intents and purposes, this is a big leap forward in medical and social integration in the provision of elderly care and services.

The trial programme adopts a multi-disciplinary approach to provide seamless care for elderly hospital dischargees by meeting both their rehabilitation and social needs. It comprises three separate pilots in Kwun Tong, Kwai Tsing and Tuen Mun districts.

In each of these pilot projects, there is a discharge planning team set up under the concerned Hospital Authority hospital, and a home support team operated by a non-governmental organisation, to provide pre-discharge and post-discharge services for the elderly patients such as formulation of discharge care plans and provision of transitional community care and support services.

The pilot in Kwun Tong, the district which has the largest number of elders among its population, was launched in March 2008. As at June this year, there were about 3,000 elder beneficiaries in this district alone. In Kwai Tsing, we have about 2,400 elder beneficiaries since the pilot started in August 2008. Tuen Mun Hospital launched its pilot programme in July this year, targeting elderly patients in Tuen Mun and Yuen Long. It is expected that a total of about 20,000 elders and 7,000 carers will be served under the three pilots.

Carers of elders often bear the brunt of looking after our senior citizens. Appreciating the heavy workload and immense difficulties faced by carers, we launched the district-based scheme on carer training in October 2007 to promote basic elderly care skills through training programmes at district levels, and to engage those who have completed training to provide carer services.

The Social Welfare Department and Department of Health have jointly developed a comprehensive set of training materials, which included understanding of the common ailments in elders and the relevant care skills as well as the psychological changes elders may undergo as they age.

The first round of training has been completed with more than 750 individuals trained. Feedback was very positive. More than half of the participants had joined the pool of carer-helpers. The second round of training commenced in March this year. It is expected that another 1,500 individuals will be trained in a year's time.

At present, there are over 26,000 residential care places for elders in Hong Kong. We are mindful of a viable support system for elders and carers in institutionalised settings. To enhance the support for infirm and demented elders staying in subsidised residential care places, the Government has been providing infirmary care supplement and dementia supplement to residential care homes.

Eligible residential care homes can make use of these supplements to employ additional staff, including physiotherapists, occupational therapists, registered or enrolled nurses, health workers and care workers, et cetera, to enhance the care for needy elders.

Apart from financial subsidies, the Government has been supporting residential care homes for elders in many ways to enhance their capability in taking care of elders.

In particular, doctors and nurses of the Hospital Authority's community geriatric assessment teams and psychogeriatric teams, as well as the Department of Health's visiting health teams, pay regular visits to residential care homes to provide medical assessments and support services for elderly residents in need. Community nurses will also provide on-site nursing care for elderly residents to ensure that they receive appropriate care.

To alleviate the problem of nurse shortage in residential care homes for elders, the Social Welfare Department has been collaborating with the Hospital Authority to organise a two-year full-time enrolled nurses training programme for the social-welfare sector since 2006.

Four classes were organised between 2006 and 2008. Another four classes will be organised in phases from now to 2011. A total of 930 training places will be provided in all eight classes.

The tuition fees for the training are subsidised by the Government. Graduates are required to work in the social-welfare sector for at least two years after graduation. Trainees of the first two classes of the enrolled nurses training programme graduated in April and October 2008 respectively. Of the first batch of graduates, 85% are now working in the social-welfare sector.

I firmly believe that with the joined-up efforts among the medical and social sectors, professionals, carers in the neighbourhood, Government and the non-governmental sectors, we should go a long way towards strengthening the primary care for elders, in particular at the rehabilitation stage.

Secretary for Labour & Welfare Matthew Cheung gave this address at the "CADENZA Symposium 2009: Primary Care & Older Persons - Key to Medical & Social Integration".