Health-social partnership has been governed by regulations in many developed countries for some years. For instance, the government of United Kingdom has implemented a policy specifically designed to facilitate the discharge of older adults by collaborating health and social care workers in hospitals. The United States also formulated a policy to support the development of collaborative and multi-agency care services in community setting for helping those who are vulnerable and underserved including ethnic minorities, homeless people, and those without health insurance. While these services were shown to reduce the delays in hospital discharge and improve access to services, they were found to be health-dominated and the involvement of service users in strategic design and planning was lacking. As a result, the actual process in practice was reported to be poor and a true model of health and social care partnership was not attained. Currently in Hong Kong, health-social partnership has not yet been driven and guided by policy. It is still unknown for researchers and practitioners as how to effectively build a seamless working partnership among two different disciplines and sustain in the community to support the independent living of older adults.

Introduction: There is a growing body of literature supporting the involvement of a health-social approach using complex interventions in enhancing self-care management among community-dwelling older adults. However, there is a paucity of research on how this intervention strategy implements and disseminates in a real community setting. Bridging the gap between research-based evidence and primary health policy and practice is a considerable challenge to researchers, service providers and policymakers. The present pilot study aims to test the feasibility and acceptability of an evidence-based health-management intervention programme to be incorporated into the existing community services provided in the elderly centers. Results of this pilot study will provide important information if the health-social partnership program rooted in the community is acceptable and feasible and factors that may facilitate or hinder implementation when reaching the target group of older adults dwelling in the community. The preliminary outcomes of enhancing self-management and older adults in maximizing their independence in their home environment will also be examined.

Method: The present pilot study adopts an effectiveness-implementation hybrid design and intends to 1) evaluate the effectiveness of a community-based Health-Social Partnership Programme (HSPP) and 2) explore the reach, adoption, implementation, and maintenance of adopting HSPP in the community. The potential subjects will be recruited from the member list of a community centre of the Hong Kong Lutheran social services if they are (1) aged 60 or above, and (2) cognitively competent. Subjects will receive nurse-led case management supported by a social service team. Factors that hinder or facilitate the program delivery will also be examined to determine the implementation and sustained effects of the programme. The measures include the components of RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. Data will be collected at pre-intervention (T1), post-intervention (T2), and 3 months after intervention (T3).

Discussion: There are conventional randomized controlled trials testing the effects of community-based programs but these trial designs tend to control the contextual factors rather than incorporating the program in the real environment. Positive outcomes may have been produced in these trials but it is uncertain whether the tested intervention program can be rooted in the real life context and sustain in practice. This pilot study chooses to use the hybrid model to not only test the effectiveness but also examine the measures relating to implementation.

Inclusion Criteria:

• aged 60 or above
• cognitively competent with the Hong Kong version of Montreal Cognitive Assessment (HK-MoCA) with score ≥ 22

Exclusion Criteria:

• not communicable
• not reachable by phone
• not living at home
• bedbound
• with known psychiatric problems with recent hospitalization within last 6 months
• already engaged in structured health or social programmes
• will not stay in Hong Kong for the current three months