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1.2 POSITIONING THE PATIENT AS THE “INTEGRATOR OF
SERVICES” IN A PERSON HEALTH JOURNEY — ENABLE
PERSON HEALTH PATHWAYS

Everybody should have access to, and ownership of, their personal health records.
We recommend continuous efforts be directed at developing a “patient

portal” as part of the Electronic Health Record Sharing System (eHRSS) that
empowers patients to monitor their own health more closely, integrates them
into the care process and enables coproduction of health. The portal should
offer various online functions including information to help people remain healthy,
appointment booking, and prescription information and requests. At the same
time, person-centred care services need to be coordinated across different care

settings and service providers. Applications should be developed to enable patients

and caregivers to become integrators of their own care. Technology should enable

patients to become integrators of their own care where applications should be
developed to allow patients to download records from various service providers.
Furthermore, telehealth services should be developed and expanded to increase
access to services and reduce unnecessary use of accident and emergency
services. The remote service will empower people to take charge of their own
health. Furthermore, 24-hour triage hotlines should be set up to help people make

informed healthcare choices anytime, be it primary care advice, triaging for specific
symptoms, nurse calls or management of health provider appointments.

2. ACHIEVING PRIMARY CARE-LED
INTEGRATED CARE —

WE NEED TO REORGANISE HOW SERVICES ARE
DELIVERED TO STRENGTHEN INTEGRATION WITHIN
AND BETWEEN PROVIDERS AND SECTORS

2.1 STRENGTHEN HEALTH SERVICES INTEGRATION THROUGH
DEVELOPING NEW MODELS OF CARE

Service delivery needs to be reorganised to become more integrated, more
accessible and enable patients to stay in the community. This requires altering how
services in primary care and hospitals are organised and delivered so they work more
effectively together. Public health functions of health protection, health promotion,
disease prevention, surveillance and response, and emergency preparedness
needs to be integrated with primary and specialist care. In necessitating the
provision of holistic person-centred care, integrating services delivery is not
limited to overcoming fragmentation and segmentation within the health system,
but also involves integration of care between health and social care services. In
recommending the need for system integration, we put forward a conceptual
model of integrated health services (Figure). In this hub and network model
for integrated health services, we emphasise the need to consider community
and networks, and primary care hubs and networks. Building on the existing
District Health Centre (DHC) model currently piloted in the Kwai Tsing District, the
community and primary care hubs offer preventive, curative and rehabilitative care
from multidisciplinary teams and connect people to appropriate services. They work
to make best use of available resources and ensure high-quality care by building
links between stakeholders. These relationships (between stakeholders, public and
private service providers, and medical and social sectors) will be enabled through
networks. These will also link providers of specialist and hospital care, both with
each other and with primary care providers. This will also foster professional
integration between primary care doctors, allied health professionals, social sector

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