Trial History Detail on 2016-05-09




CREC 2016.204

Hong Kong Jockey Club Charities Trust

Professor Samuel Yeung-shan WONG


Not Applicable

Wing Yin TAM

Room 04, 4/F, Lek Yuen Health Centre,
9 Lek Yuen Street,


The Chinese University of Hong Kong

Hong Kong

Samuel Yeung-shan WONG

4/F, School of Public Health, Prince of Wales Hospital, Shatin, New Territories, Hong Kong


Division of Family Medicine and Primary Health Care, The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong

Hong Kong

The Efficacy of Complex Integrated Community Primary Care Programme in People with Complex Chronic Conditions

The Community Primary Care Programme: Enhancing care of people with complex chronic conditions


Hong Kong



Joint CUHK-NTEC Clinical Research Ethics Committee


With 2 or more long term chronic diseases


For those who are eligible for the case clinic, they will be seen by a case management professional (a social worker/nurse) and a management plan will be made and the medical and psycho-social needs will be addressed with input from the multidisciplinary team members including the participating NGOs. For all patients enrolled, baseline assessments and subsequent outcome and process evaluations of health related indicators will be measured by the project coordinator regularly to monitor the quality and progress of the programme. For these patients, a complex integrated primary care programme with three components will be provided: 1) Family members/carers resilience and support programme including a) support group interventions e.g. connecting existing network and resources and online group discussion and webpage modules; b) professional education interventions such as behavioral management, self enhancement skills and chronic disease education; 2) Patients empowerment programme including a) self-management programme b) transformative learning and c) socialization to build up partnership between individuals and illness, family, carers and health professionals and 3) Direct Intervention on family members or patients: counseling/therapy intervention targeted on specific treatment needs and home visits to help patients with specific health or social needs. Assessment and progress monitoring will be carried on month 0 and month 24.



2 years

1-8 week






1) Chinese

2) Age 60 or above

3) With 2 or more long term chronic diseases

4) Patient from the public and private primary care clinics with complex psychological and social needs (i.e. immigrants, single mothers, elderly who lives alone with multiple health problems etc.)

5) Service user from community non-government organizations (NGO) in the region with more than one chronic medical condition

1) Cognitive impairment with MMSE score less than 18

2) Immobility. Confined to a bed or chair for > 22 hours per day; for at least 4 of the past 7days.

3) Lacking capacity of consent.



Both Male and Female



Not Applicable

Not Applicable

Single group




Not Yet Recruiting

The change of EQ5D5L from baseline to the end of month 24

EQ5D5L questionnaire

Month 0 and month 24.

Change of lifestyle (e.g. physical activities level, smoking, alcohol consumption)

Physical activities level will be assessed by International Physical Activity Questionnaire. Smoking and alcohol consumption habit will be recorded by history taking and AUDIT-C questionnaire.

Month 0 and month 24.

Change of health parameters (eg, blood pressure, pain assessment and body mass index (BMI),

Blood pressure data will be collected by blood pressure monitor, pain assessment will be done by Brief Pain Inventory, Body mass index will be calculated by the formula: Body weight/(Body Height x Body Height)

Month 0 and month 24.

Change of health service utilization pattern (having a family doctor, self-care, use of public primary care clinics (ie, the general outpatient clinic (GOPC)) and accident and emergency service)

Change of health service utilization pattern will be recorded by history taking

Month 0 and month 24.

Change of psychosoical health (e.g. anxiety, depression, social support, loneliness level and meaningfulness in life),

Anxiety level will be assessed by GAD-7 questionnaire, Depression level will be assessed by PHQ-9, social support can be measured by MSPSS questionnaire, loneliness level can be measured by 6-item De Jong Gierveld Loneliness Scale and meaningfulness of life will be assessed by the C-MLQ.

Month 0 and month 24.

Change of self care ability, cognitive assessment and habit of seeking health information

Self care ability will be assessed by IADL questionnaire, cognitive assessment will be done by MMSE questionnaire and habit of seeking health information will be done by eHEALS questionnaire and a social media utilization questionnaire

Month 0 and month 24.



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