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and non-governmental organisation (NGO) workers, and help forge continuity of

care between medical and community services. We have identified the following
key mechanisms contributing to the design and ultimate delivery of integrated care:

(i) Designing care across the life course such that care pathways are tailored
for the holistic physical, social and spiritual needs of individuals.

(ii) Organising providers and settings such that coordination facilitates
seamless transitions throughout the care pathway.

(iii) Managerial processes must be in place and executed through collaboration
with different sectors to address wider determinants of health and ensure
necessary resources are available. Management of resources invested is

critical for efficiency and effectiveness. Mechanisms for monitoring, evaluation,
review and renewal of current service models is crucial for sustainability.

(iv) Clinical governance needs to be strengthened to monitor and evaluate how
care is being coordinated to meet holistic needs of patients. Mechanisms
enabling well-planned service and care pathways should be in place to
facilitate the delivery of a continuum of care across settings and provider
transitions.

2.2 ACCELERATE THE PACE OF PRIMARY CARE DEVELOPMENT
IN HONG KONG

Primary care is a vital component of our current health system that needs to be
strengthened substantially. It needs to be comprehensive to address a majority of
personal holistic needs, coordinated across different care providers and service
settings for smooth care transitions along the patient care pathway, continuous to
cater for needs across the life course and accessible for patients to initiate necessary
interactions with health service providers (Donaldson, Yordy, & Vanselow, 1994). In
moving forward, we must create, train and continually invest in the right workforce
with the right skills for primary care delivery and devote attention to the appropriate

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