A father has spent two weeks in a public hospital geriatric ward. On the day of discharge, the nurse hands over a pile of discharge papers with one reminder to follow up at home, and the procedure is complete. The family is left holding the papers and confused. Who is responsible for follow-up? How should the wound be handled? Where will the rehabilitation training continue? This happens in public hospitals every day. What the discharge papers do not say is that Hong Kong has four different institutional pathways, each serving patients with different needs.
After discharge from a Hong Kong public hospital, there are four pathways the patient can be linked to: the Hospital Authority community nursing service and CGAT (geriatric follow-up), the Social Welfare Department’s day community rehabilitation centres (CRDC, which accept discharged patients), geriatric day hospitals, and the Community Rehabilitation Network of the Hong Kong Society for Rehabilitation (CRN, a self-help network for people with long-term conditions). The benefit of linking up with community services early is backed by solid data. Coordinated early supported discharge (ESD) and transitional care have been shown to shorten hospital stay and lower the risk of readmission and death (Langhorne 2017; Buurman 2016). The real difficulty is therefore not a lack of services but which pathway suits which situation. The sections below take them one by one.
Who each of the four rehabilitation pathways serves
Many families share the same blind spot. They assume that discharge means the end of rehabilitation, when it is really a handover from hospital to community. Research shows that nurse-led transitional care (a comprehensive geriatric assessment during the hospital stay followed by several home visits after discharge) may not improve the primary outcome of self-care in daily activities at 6 months, but it significantly lowers mortality. Among 674 participants, mortality was 25.2% in the intervention group and 30.9% in the control group, HR 0.75 (Buurman 2016). In other words, whether a professional team takes over after discharge directly affects the patient’s survival. The four pathways in Hong Kong do not overlap. They divide the work according to actual need. Nursing needs are handled by community nurses, geriatric assessment and long-term medical follow-up go to CGAT, intensive rehabilitation training is taken over by the Social Welfare Department’s CRDC, and self-management of long-term illness can be done through the CRN of the Hong Kong Society for Rehabilitation. Accurate sorting greatly reduces waiting time and mismatched resources.
To see the role of this handover in the whole recovery, first read the idea of the “vulnerable period” in the practical guide for caregivers on bringing the patient home after discharge. For the referral arrangements that should be completed early during the hospital stay, see the caregiver checklist before discharge.
Hospital Authority services: community nursing and the Community Geriatric Assessment Team (CGAT)
This pathway within the Hospital Authority is medically led. Two of its services are often confused, but they cover very different areas. Taking the clinical evidence as a whole, geriatric rehabilitation services (in either inpatient or day hospital form) significantly lower mortality and long-term care home admission compared with usual care, and also improve physical function and cognition (Wong 2024, a combined analysis of 29 studies and 7,999 patients, with RR 0.84 for death and RR 0.86 for care home admission). This shows that patients benefit once a geriatric team takes over their follow-up.
| Community nursing service (community nurses) | This service needs a referral from an inpatient or outpatient doctor. Community nurses visit the home to handle the nursing needs after discharge, for example caring for wounds, stomas and catheters, and teaching the patient to manage diabetes, medication and stroke rehabilitation exercises. The service covers daily nursing care only. It does not carry out a full assessment or refer on to other services. |
| Community Geriatric Assessment Team (CGAT) | This is an outreach team led by geriatric medicine, and a referral from a public hospital or specialist is required. The team provides home visits for specialist medical care, geriatric assessment and follow-up for older people, including residents of care homes. It suits older people who need a specialist assessment and continuing medical follow-up. The enquiry number of the Tuen Mun team is 2468 5713. |
Social Welfare Department service: day community rehabilitation centres (CRDC)
If the patient needs continuing rehabilitation training after discharge, and not just medical nursing, a day community rehabilitation centre (CRDC) funded by the Social Welfare Department is the most suitable next step. According to the stated purpose of the service, CRDCs aim to provide professional and psychosocial rehabilitation training for discharged patients. In other words, they are designed for people who have just left hospital and still need continuing training.
Who it serves (per the Social Welfare Department)
- Discharged patients aged 15 or above
- People with stroke or brain injury
- People with physical disability, or whose mobility is affected by illness
- People who need continuing rehabilitation training
How to apply and get referred
- A referral from a hospital or social worker is generally needed
- Social Welfare Department rehabilitation services enquiry hotline: 2343 2255
- The focus of the service is rehabilitation training and not general daily nursing
- Places are limited, so enquire and arrange early, before discharge
In practice, the barrier families meet most often is mistaking the Social Welfare Department’s day rehabilitation centre for the Hospital Authority’s geriatric day hospital as the same service, and applying through the wrong channel. In fact they belong to the social welfare system and the medical system respectively, and their fees and referral routes differ. The next section sets out the clinical evidence and role of each.
Geriatric day hospitals and day community rehabilitation centres (CRDC) compared
The biggest difference between the two is whether the service is medically led or led by social welfare. The Hospital Authority’s geriatric day hospital is run by a medical team that carries out clinical assessment and rehabilitation treatment. Evidence shows that, compared with a lack of comprehensive care, the day hospital model effectively lowers the risk of death or poor outcome (Forster 1999, a combined analysis of 12 controlled trials with 2,867 older people, with OR 0.72 for death or poor outcome and OR 0.61 for functional decline). The Social Welfare Department’s CRDC is a welfare-based rehabilitation training service for discharged patients with stroke, brain injury or physical disability. When looking for a service, the first step for families is therefore to work out whether the patient needs the medical pathway or the social welfare pathway, before choosing a particular organisation.
- Rehabilitation training funded by the Social Welfare Department
- Accepts discharged patients: stroke, brain injury, physical disability, aged 15 or above
- Geared to continuing, intensive rehabilitation training after discharge
- Referral through a hospital or social worker; enquiries 2343 2255
- Led by the Hospital Authority geriatric medical team
- Mainly geriatric assessment and medical rehabilitation
- Evidence of lower risk of death or poor outcome (Forster 1999)
- Referral through a public hospital or specialist
Community Rehabilitation Network (CRN) of the Hong Kong Society for Rehabilitation
The fourth pathway is not for intensive rehabilitation after an acute discharge. It is designed for people with long-term chronic illness. If the patient has a long-term condition such as diabetes, kidney disease or heart disease, and has not just left hospital needing intensive rehabilitation training, putting the patient on the waiting list for a Social Welfare Department CRDC place is a mismatch of resources. Such patients are better suited to the Community Rehabilitation Network (CRN) of the Hong Kong Society for Rehabilitation.
Why early linkage matters: the clinical evidence on ESD and transitional care
Why is linking up services within the first few days after discharge so important? There is a large body of objective data behind early handover. Whether for stroke patients, older people discharged from general medicine, or patients receiving nurse-led transitional care, the earlier a coordinating team takes over, the more hospital days and the risk of poor outcomes fall.
Referral arrangements need to start before discharge. Research shows that the most effective model of transitional care (Buurman 2016) carries out the geriatric assessment while the patient is still in hospital and makes the first home visit soon after discharge. The family should therefore ask the ward social worker, while the patient is still an inpatient, whether to be referred to a CRDC or to community nursing, and should not wait until after discharge to arrange it in a rush.
Which service to choose in different situations
Choosing among the four pathways can be reduced to a simple principle: first separate medical from social welfare, then match the need to nursing, assessment, rehabilitation training or long-term self-help. The most common classification is below:
- Needs care of a wound, stoma or catheter, or guidance on medication → Hospital Authority community nursing (a doctor’s referral is needed)
- Needs a specialist geriatric assessment and continuing medical follow-up → CGAT or a geriatric day hospital
- Has just left hospital and needs intensive rehabilitation training (stroke, brain injury or physical disability) → Social Welfare Department CRDC
- Self-management of a long-term chronic illness (diabetes, kidney disease or heart disease) and mutual help among patients → CRN of the Hong Kong Society for Rehabilitation
- A patient with a long-term chronic illness should not wait for a CRDC place, so that the wrong queue and the wrong resource are avoided
The number of community nursing visits or day hospital sessions in the public system is always limited. If the patient is in the vulnerable period after discharge and wants more training, private home rehabilitation can be used as a bridge, with targeted training carried out in the familiar home environment. For how recovery progresses after the discharge transition period and how long each stage takes, see the timeline of the recovery phase after discharge.
When a physiotherapist can help
If the family is not sure which pathway an older relative should take, or is on the waiting list for a CRDC place while the patient is in the vulnerable period after discharge and cannot simply wait, the home rehabilitation service provided by Nova Health’s registered physiotherapists can assess the home environment and the patient’s actual mobility at home. The therapist helps the family sort the patient to a suitable public or social welfare pathway, and adds training volume between public hospital sessions, so that the early window after discharge is not wasted.