Chronic Disease Co-Care Pilot Scheme

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Scheme Objectives

To provide convenient screening services for diabetes mellitus (DM) and hypertension (HT), and provide blood lipid testing
To provide a tailored health management plan for Scheme Participant to control risk factors for chronic diseases
To prevent chronic diseases at an early stage, thus reducing related complications
To realise the goal of “Family Doctor for All”

Scheme Content

Screening Services

Family Doctor will perform assessment and arrange investigations for screening
Family Doctor will arrange blood test(s) at designated medical laboratory
Family Doctor will explain investigation report and diagnosis, and formulate appropriate health management plan

Health Management Plan

Family Doctor will provide a maximum of six subsidised consultations annually to Scheme Participant diagnosed with HT and/or DM, while those with prediabetes will be offered a maximum of four subsidised consultations annually together with the necessary medications
If Scheme Participants are diagnosed with hyperlipidaemia, they are entitled to a maximum of four subsidised consultation visits in the first year, and a maximum of two subsidised consultation visits annually from the second year onwards; if they are also diagnosed with prediabetes or suffering from DM or HT, they are entitled to a maximum of four or six subsidised consultation visits per year respectively together with the necessary medications
Family Doctor will arrange necessary laboratory tests and examinations as required
DHC/DHCE will arrange nurse clinic and/or allied health services according to referral by the Family Doctor and condition of the Scheme Participant

Coordination and Support from DHC/DHCE

To follow up and coordinate health management plan of Scheme Participant
To set health goals together with Scheme Participant based on Family Doctor’s suggestion
To enhance Scheme Participant’s self-health management, promote Scheme Participant empowerment and help to build a healthy lifestyle

Eligibility

Hong Kong residents aged 45 or above*
No known medical history of diabetes mellitus or hypertension
Have enrolled in the eHRSS and registered as a DHC/DHCE member

* Holding (1) a valid Hong Kong Identity Card within the meaning of the Registration of Persons Ordinance (Cap. 177), except those who obtained their Hong Kong Identity Card by virtue of a previous permission to land or remain in Hong Kong granted to them and such permission has expired or ceased to be valid, or (2) a valid Certificate of Exemption within the meaning of the Immigration Ordinance (Cap.115)

Caring Services

Family Doctor for All (Press above icon to pair Family Doctor)

Scheme Participant can choose his/her preferred Family Doctor to receive personalised and comprehensive primary healthcare services

Comprehensive Care

Family Doctor will formulate health management plan based on screening results and provide medical consultations, medications as well as referrals to laboratory investigations, nurse clinic and allied health services to meet the medical needs of Scheme Participant

Personalised Case Management

DHC/DHCE will coordinate health management group activities, nurse clinic and allied health services based on the health management plan of Scheme Participant

Integrated Care by Professional Team

A multidisciplinary team including Family Doctor, nurses, allied health professionals (optometrist/ podiatrist/ dietitian/ physiotherapist) and DHC/DHCE will support various medical needs of Scheme Participant

eHealth App Support

Scheme Participant can use the eHealth App to browse health information, access personal health record, as well as record and self-monitor certain health parameters such as blood pressure and weight

Government Subsidy (Press above icon to know the details of Government Subsidy)

The Government will partially subsidise medical consultations with Family Doctor, medications, laboratory investigations, nurse clinic and allied health services under the Scheme. Scheme Participant is required to pay the co-payment fee only

Incentive Mechanism (Press above icon to know the details of Incentive Mechanism)

Starting from the second programme year, Scheme Participant who achieves health incentive targets will enjoy a one-off reduction in co-payment fee by $150 maximum (i.e. the co-payment fee recommended by the Government) for the first subsidised consultation in the following year of the Scheme

Bi-directional Referral Mechanism with HA

Under the bi-directional referral mechanism developed with the Hospital Authority (HA), Family Doctor can arrange with the coordination by DHC/DHCE for Scheme Participant with clinical needs to receive a one-off specialist consultation at an HA designated Medicine Specialist Out-patient Clinic, according to pre-defined criteria and guidelines, for clinical advice on the health management plan, so as to facilitate Scheme Participants in receiving continuing and co-ordinated primary healthcare services in the community.

Besides, to cater to the healthcare needs of the underprivileged groups, the Government piloted preventive screening and care services for the groups in the General Out-patient Clinics (GOPC) of the Hospital Authority (HA). Comprehensive Social Security Assistance (CSSA) Scheme recipients, Old Age Living Allowance (OALA) recipients aged 75 or above, or holders of valid Certificate for Waiver of Medical Charges who are interested in joining the programme, may be arranged to receive the service at designated HA GOPCs via District Health Centres (DHC) / DHC Expresses, with the same service scope as the CDCC Pilot Scheme. For details, please click here to download the service information.