Evaluation Study of a Collaborative Stepped-Care and Productive Ageing Model for Elderly Mental Wellness in Hong Kong
Phase: NA
Conditions: Depressive Symptoms
Sponsor: The University of Hong Kong

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Jockey Club JoyAge Extension: Territory-Wide Implementation of Holistic 
Support for Elderly Mental Wellness  
 
Date of the document: 10th April, 2021 
 
INVESTIGATORS  
Terry YS Lum (Principal Investigator) 
Department of Social Work and Social Administration, HKU 
Gloria HY Wong (Co-Principal Investigator) 
Department of Social Work and Social Administration, HKU 
Wai Chi Chan 
Department of Psychiatry, HKU  
Jennifer YM Tang 
Samson Tse 
Department of Social Work and Social Administration, HKU 
Daniel FK Wong 
Department of Social Work and Social Administration, HKU 
Paul WC Wong 
Department of Social Work and Social Administration, HKU 
Siuman Ng 
Department of Social Work and Social Administration, HKU 
Vivian Lou 
Sau Po Centre on Ageing, HKU  
Department of Social Work and Social Administration, HKU 
Ricky Kwok 
Department of Electrical and Electronic Engineering, HKU 
Zvi Gellis  
School of Social Policy & Practice, University of Pennsylvania  
Martin Knapp  
Department of Health Policy, London School of Economics and Political Science 
 
 
 

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PARTNERING ORGANIZATIONS 
Aberdeen Kai-fong Welfare Association Social Service 
Caritas – Hong Kong 
Christian Family Service Centre 
Haven of Hope Christian Service 
Hong Kong Christian Service 
Hong Kong Sheng Kung Hui Lady MacLehose Centre 
Hong Kong Sheng Kung Hui Welfare Council Limited 
Hong Kong Young Women’s Christian Association 
New Life Psychiatric Rehabilitation Association 
St James’ Settlement 
The Hong Kong Society for the Aged 
The Mental Health Association of Hong Kong 
The Neighbourhood Advice-Action Council 
Tung Wah Group of Hospitals 
 
 
 

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Background 
The Jockey Club Holistic Support Project for Elderly Mental Wellness (JC JoyAge) has 
developed and implemented a collaborative stepped care model for older persons at-
risk of or with depression in four districts in Hong Kong since 2015 (Clinical Trials 
Identifier: NCT03593889). Results from JC JoyAge show that the collaborative 
stepped-care model is effective in improving older persons’ mental wellness, and the 
specialised training and engagement of Peer Supporters are effective in building 
capacity in the community. The proposed impact extension programme will be four 
years (from 2020 to 2023), and the overall goal is to expand the JC JoyAge model to 
all 18 districts in Hong Kong, to provide integrated and evidence based mental health 
services to older adults with subclinical depressive symptoms, with the hope of model 
adoption in regular service upon project completion. 
Objectives 
a) To implement JC JoyAge clinical protocol and guidelines to coordinate care 
among community mental health and elderly services centres for elderly 
mental wellness in 18 districts;  
b) To engage vulnerable and at-risk older adults in the community through 
productive ageing activities and mental wellbeing self-management training;  
c) To enhance the capacity of social service staff in handling elderly depression 
through specialized and infusion training and knowledge exchange;  
d) To raise public awareness and elderly mental health literacy among family 
members, neighbours, community stakeholders, and the general public to 
encourage early detection/help-seeking on depressive risk of older adults; and  
e) To establish evidence of the effectiveness and cost-effectiveness of JC JoyAge 
Phase II model.  
 
Methods 
Design 
This intervention study is designed as a prospective, open-labelled, single-arm trial. In 
the one-group pretest-posttest design, data will be collected at the baseline (T0), after 
completion of the intervention (T1), and after completion of the exit-plan (T2). 

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Participants 
Older people with mild to moderately severe depressive symptoms (n=3,000) recruited 
from 14 JoyAge partner non-governmental organisations (NGOs) in 18 districts in 
Hong Kong.  
 
The inclusion criteria for participants are: 
 age 60 years or above; and 
 have depressive symptoms of mild level or above; and 
 able to give informed consent to participate 
 
The exclusion criteria for participants are: 
 known history of autism, intellectual disability, schizophrenia-spectrum disorder, 
bipolar disorder, Parkinson’s disease, or dementia; and 
 (temporary exclusion criteria) imminent suicidal risk; and 
 difficulty in communication 
 
Assessment Procedures 
After basic screening, baseline evaluation (T0/intake) will be performed by trained 
social worker employed by NGOs and clinical information will be used for triage. After 
completion of the intervention or drop-out, a progress review evaluation (T1/review) 
will be done by social worker as well, and a client is discharged if he/she meets the exit 
criteria at T1. For dischargeable client, a 2-month exit plan will be provided, and he/she 
will be assessed at the end of the exit period (T2/exit) by Peer Supporters, specifically 
on progress in personal goals of recovery. 
Assessment will last for around 60 minutes for all participants at T0 and T1, and for 
around 30 minutes at T2 for those who are eligible for discharge. 
 
Interventions 
Participants in the intervention group will receive a collaborative stepped care 
programme provided by registered social workers and trained Peer Supporters from 
elderly service units, the Districts Elderly Community Centres (DECC), and mental 

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health service units, the Integrated Community Centre on Mental Wellness (ICCMW), 
all local NGOs. In the collaborative stepped care model (see Table 1), older persons are 
matched to the intervention module that most suits their current needs. The person does 
not have to start at the lowest level of intervention to progress to the next level of 
intervention. Rather, they enter the service with the intervention level aligned to their 
needs, e.g., level of risks, symptom severity (measured by the Patient Health 
Questionnaire, PHQ-9), and intervention response. Home visits or other format of 
contact will be delivered by trained Peer supporters employed by the NGOs to detect 
and engage hidden cases.  
 
Table 1. JoyAge Collaborative Stepped-Care Service 
 
Indicated Prevention 
for Mild Symptoms 
Clinical Intervention 
for 
Moderate Symptoms 
Intensive Clinical 
Intervention for 
Moderately Severe 
Symptoms 
Intervention 
goal 
To reduce depressive 
symptom level to 
normal level, enhance 
resilience 
To reduce depressive 
symptom level to mild 
depression or below 
To reduce depressive 
symptom level to 
moderate depression 
or below 
Key 
intervention 
mode 
Psychoeducation on a 
specific topic 
(insomnia, pain, stress, 
and anxiety), or  
low-intensity 
psychotherapy 
High-intensity 
psychotherapy 
High-intensity 
psychotherapy 
Principal 
team 
DECC 
DECC and ICCMW 
ICCMW 
 
For older adults with mild depressive symptoms (PHQ-9 score 5-9), 6-8 weeks of 
indicated prevention with psychoeducation or low-intensity psychotherapy would be 
provided by the project social workers in the DECC. For participants with moderate 
symptoms (PHQ-9 score 10-14), 6-8 weeks high-intensity clinical intervention, mainly 
cognitive behavioral therapy (CBT), would be provided by project social workers from 
the DECC and ICCMW. For those with moderately severe depressive symptoms, 
individual CBT or group CBT at higher frequency would be provided by the project 
social workers from the ICCMW.  
Participants should be stepped up to clinical intervention at a more intense level if they 
showed increased level of depressive symptoms after receiving one rounds of services, 

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and stepped down to lower level if they showed improvements. Participants showing 
severe depressive symptoms or increased suicide risk should be referred out to other 
appropriate services. In the review session after completion of the intervention, when a 
person is assessed to be meeting the discharge criteria, a 2-month Exit Plan involving a 
Peer Supporter follow-up should be invoked. The key social worker will work with the 
client to develop a 6- to 8-week Mental Health Wellness Plan (e.g., activity scheduling) 
to further improve or consolidate the protective factors.  
All intervention would be conducted by registered social workers who are trained by 
this project and employed by the NGOs. The trained Peer Supporters will be matched 
to individual older adults to walk them through the process with regular follow-up until 
discharged or referred out.  
Measurements 
Basic demographics including age, gender, marital status, education (years and highest 
attainment), and work experience will be collected at T0. At following time points, only 
updates of the basic demographics will be recorded. At both T0 and T1, a full set of 
assessment will be conducted; and at T2, only the primary outcomes would be measured. 
Primary outcomes 
1. Depression: The Patient Health Questionnaire (PHQ-9) (Kroenke, Spitzer, & 
Williams, 2001): a 9-item instrument that incorporates depression diagnostic 
criteria with other leading major depressive symptoms,  and rates the frequency of 
the symptoms which factors into the scoring severity index. PHQ-9 scores of 5-9, 
10-14, 15-19, 20 and above represent mild, moderate, moderately severe, and 
severe depression. 
2. Anxiety: Generalized Anxiety Disorder 7-item scale (GAD-7) (Spitzer, Kroenke, 
Williams, & Löwe, 2006), a 7-item scale, responses to each item are rated on a 4-
point Likert scale and range from 0 to 3. It taps on the most prominent diagnostic 
features for GAD and scores of 5, 10, and 15 are taken as the cut off points for mild, 
moderate, and severe anxiety, respectively.  
3. Loneliness: UCLA loneliness scale (UCLA-3) (Hughes, Waite, Hawkley, & 
Cacioppo, 2004), a 3-item self-report measuring individual’s perceived loneliness. 
Each item is evaluated with scores ranging from 0 (never) to 3 (often), total score 

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is the sum of all items, and higher score indicates higher level of perceived 
loneliness.  
4. Self-harm risk assessment: Assessment by social service staff on participant’s risk 
of self-harm (yes or no answers to 10 items) and harm to others (yes or no answers 
to 4 items), and in the end social service staff will give an overall evaluation of 
suicidal risk score ranging from 0-No to 3-High. 
5. Wellbeing – quality of life: EQ-5D-5L (Herdman et al., 2011), a generic 
preference-based measure of health at five dimensions (5D), each with five levels 
(5L) of problems, and the five dimensions are: mobility, self-care, usual activities, 
pain/discomfort, and anxiety/depression. The traditional Chinese version for Hong 
Kong developed by EuroQol Group would be used. 
6. Personal recovery: Recovery Assessment Scale (RAS), validated Chinese version 
(Mak, Chan, & Yau, 2016), a 24-item RAS assesses personal recovery, specifically 
focusing on self-determination and hope as the major areas of recovery. Items are 
rated on a five-point likert scale. For the purpose of this study, only the five items 
from the “Goal and success orientation” factor would be included. 
7. Treatment and recovery goal: Self-developed questionnaire asking about present, 
anticipated, and desired personal best in personal recovery goal, social network, 
and activities to participate in the community.   
8. Health care expenditures: Client Service Receipt Inventory (CSRI) (Chisholm et 
al., 2000), to collect the current types and level of social services which comprise 
the care package of each participant, and a locally adapted short version would be 
developed for this purpose. Based on the localized health utilities and duration, we 
will further calculate the QALYs. The service utilization data will be obtained from 
Health Authority1, covering information on outpatient visits, hospitalization days, 
Accident and Emergency service utilization, types of medications and operations, 
other diagnoses, self-harm, and any other major cost items that may be affected by 
depression with cost implications. 
                                                          
1 Separate application has been submitted to Hospital Authority (HA) Institutional Review Board for 
HA data use. 

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Secondary outcomes 
1. Lifestyle: Typical Day, a semi-structured interview asking clients about their 
typical day activities in three domains, physical, social, and mental. A combination 
of being active in at least two domains would be used as one of the exit criteria. 
2. Cognition: Hong Kong Montreal Cognitive Assessment 5-Minute Protocol (HK-
MoCA 5-Min) (Wong et al., 2015), a validated and reliable cognitive screen for 
stroke and transient ischemic attack. It includes four items examining attention, 
verbal learning and memory, executive functions/language, and orientation 
extracted from the MoCA. 
3. Support network: asking participants to list out names of people who they would 
turn to when they feel down, and when they need help for trivial things. 
4. Perceived environment: Self-developed questions of perceived residential 
environment derived from sense of community scale (McMillan & Chavis, 1986) 
and neighbourhood environment walkability scale (Saelens, Sallis, Black, & Chen, 
2002). 
5. Pain management: Using Chronic pain acceptance questionnaire (CPAQ-8) (Fish, 
McGuire, Hogan, Morrison, & Stewart, 2010), participants will rate the extent to 
which the eight statements about pain acceptance are true for them on a 7-point 
Likert scale, and higher scores indicates greater levels of acceptance.  
 
Data Analysis 
For the main outcome measures of depressive symptoms/risks, wellbeing, and personal 
recovery, repeated measures analysis and growth curve modeling with three time points 
will be applied. All results will be reported with the appropriate effect sizes, along with 
statistical significances and confidence intervals.  
To evaluate cost-effectiveness and sustained cost-effectiveness, cost-utility analysis 
will be used for analyzing data at different time-points. We focus on the quality-
adjusted life year (QALY), a generic measure of health, like a currency which combines 
the quality of life and duration of the quality of life (Luyten, Naci, & Knapp, 2016). It 
not only captures observable health outcomes but also reflects the subjective appraisals 
of how bad it is to experience these outcomes from participants’ perspective. Findings 
of cost-utility analysis will be reported as an incremental cost-utility ratio (ICUR), 

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indicating that the incremental cost per QALYs gained.  We will use STATA 14.0 
(StataCorp, 2015) for data analysis. 

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References 
Chisholm, D., Knapp, M. R. J., Knudsen, H. C., Amaddeo, F., Gaite, L., & Van Wijngaarden, B. (2000). 
Client Socio-Demographic and Service Receipt Inventory-European Version: development of 
an instrument for international research. The British Journal of Psychiatry, 177(39), s28-s33.  
Fish, R. A., McGuire, B., Hogan, M., Morrison, T. G., & Stewart, I. (2010). Validation of the Chronic 
Pain Acceptance Questionnaire (CPAQ) in an Internet sample and development and preliminary 
validation of the CPAQ-8. Pain, 149(3), 435-443.  
Herdman, M., Gudex, C., Lloyd, A., Janssen, M., Kind, P., Parkin, D., . . . Badia, X. (2011). Development 
and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L). Quality of life 
research, 20(10), 1727-1736.  
Hughes, M. E., Waite, L. J., Hawkley, L. C., & Cacioppo, J. T. (2004). A short scale for measuring 
loneliness in large surveys results from two population-based studies. Research on aging, 26(6), 
655-672.  
Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The Phq‐9. Journal of general internal medicine, 
16(9), 606-613.  
Luyten, J., Naci, H., & Knapp, M. (2016). Economic evaluation of mental health interventions: an 
introduction to cost-utility analysis. Evidence-Based Mental Health, 19(2), 49-53. 
doi:10.1136/eb-2016-102354 
Mak, W. W., Chan, R. C., & Yau, S. S. (2016). Validation of the Recovery Assessment Scale for Chinese 
in recovery of mental illness in Hong Kong. Qual Life Res, 25(5), 1303-1311. 
doi:10.1007/s11136-015-1157-6 
Nicholls, J., Lawlor, E., Neitzert, E., & Goodspeed, T. (2012). A guide to social return on investment: 
The SROI network. In. 
Peterson, N.A., P.W. Speer, and D.W. McMillan, Validation of a Brief Sense of Community Scale: 
Confirmation of the principal theory of sense of community. Journal of Community Psychology, 
2008. 36(1): p. 61-73. 
Sinclair, V. G., & Wallston, K. A. (2004). The development and psychometric evaluation of the Brief 
Resilient Coping Scale. Assessment, 11(1), 94-101.  
Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Löwe, B. (2006). A Brief Measure for Assessing 
Generalized Anxiety Disorder: The GAD-7. Arch Intern Med., 166(10), 1092-1097. 
doi:10.1001/archinte.166.10.1092 
StataCorp, L. J. C. S. (2015). Stata statistical software (version release 14). College Station, TX: 
Author, 464, 465. 
Sun, W. J., Xu, L., Chan, W. M., Lam, T. H., & Schooling, C. M. (2012). Depressive symptoms and 
suicide in 56,000 older Chinese: a Hong Kong cohort study. Soc Psychiatry Psychiatr Epidemiol, 
47(4), 505-514.  
Wong, A., Nyenhuis, D., Black, S. E., Law, L. S., Lo, E. S., Kwan, P. W., . . . Nasreddine, Z. (2015). 
Montreal Cognitive Assessment 5-minute protocol is a brief, valid, reliable, and feasible 
cognitive screen for telephone administration. Stroke, 46(4), 1059-1064.  
 
 

11 
 THE UNIVERSITY OF HONG KONG 
Jockey Club Holistic Support Project for Elderly Mental Wellness (JC 
JoyAge) 
 
Service Application and Personal Data Use Consent Form 
 
You are invited to participate in the JC JoyAge: Jockey Club Holistic Support Project for 
Elderly Mental Wellness (‘this study’). Before you decide, it is important for you to understand 
why this study is being done and what it will involve. Please take the time to read the following 
information carefully and discuss it with friends, relatives and professionals if you wish. Ask 
the project team if there is anything that is not clear or if you would like more information. 
Take time to decide whether or not you wish to take part. 
PURPOSE OF THE STUDY  
Older adults in Hong Kong face a variety of mental wellness challenges. This study aims at 
evaluating the current mental health services and the effectiveness and cost-effectiveness of the 
intervention delivered by this study, which has the goals of improving older adults’ mental 
wellness and building capacity in the community. This study lasts for four years. 
CRITERIA FOR PARTICIPATION 
You are invited to take part in this study because you have met the following criteria 1) age 60 
years or above; 2) have depressive symptoms of mild level or above; and 3) able to give 
informed consent to participate; as well as 4) without known history of autism, intellectual 
disability, schizophrenia-spectrum disorder, bipolar disorder, Parkinson’s disease, or dementia; 
5) (temporary criterion) without imminent suicidal risk; and 6) without difficulty in 
communication.  
PARTICIPATION AND WITHDRAWAL 
Taking part in this study is completely voluntary. It is up to you to decide whether or not to take 
part. If you do decide to take part, you will be given this information sheet to keep and be asked 
to sign a consent form. You can withdraw at any time without consequences of any kind. This 
will not affect the standard of care you receive. 
WHAT WILL HAPPEN 
The Jockey Club Holistic Support Project for Elderly Mental Wellness project (JC JoyAge) will 
provide a range of integrated and evidence-based mental health services. Services include 
assessment, group activities, peer support, psychotherapy, etc. The Organisation will do its 
utmost to ensure that all services are in compliance with the Code of Practice and strive to 
provide a high standard of service. You are also invited to complete a questionnaire and some 
tests twelve months and eighteen months later after the service entry. All assessments will be 
conducted by trained Social Workers or Research Assistants. During the course of this study, 
if the participants do not respond to intervention positively within 9 months, referral to existing 
services will be made. 
SERVICE MODEL UNDER STUDY 
This study is examining an impact extension of a developed and implemented collaborative 
stepped care model for older persons at-risk of or with depressive symptoms. The goal of this 
study is to establish evidence of the effectiveness and cost-effectiveness of the extended service 
models, so as to support the model adoption in regular service territory-wide in Hong Kong 
upon project completion. 
POTENTIAL RISKS / DISCOMFORTS 

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There is no known risk of participating in this type of study. 
ANTICIPATED BENEFITS 
Anticipate benefits include reduced depressive symptoms and/or risk levels, improved 
wellbeing and personal recovery, improved general health and healthy lifestyle, and fewer uses 
of primary/secondary/tertiary healthcare resources. The effect of intervention depends on your 
joint efforts and cooperation with the therapist. The therapist employs evidence-based 
psychotherapy in order to achieve the goal of intervention, but the therapist cannot unilaterally 
guarantee that the intervention will give the expected effect. Therefore, regardless of the 
outcome of the intervention, the therapist or other Project staff is not responsible for any legal 
responsibility. 
IF NEW INFORMATION BECOMES AVAILABLE 
Sometimes during the course of a research project, new information becomes available about 
the treatment that is being studied. If this happens, your therapist will tell you about it and 
discuss with you whether you want to continue in the study. If you decide to withdraw, your 
therapist will make arrangements for your care to continue. If you decide to continue in the 
study you will be asked to sign an updated consent form. Also, during the period of service 
acceptance, if it is believed that another service organization can provide services that are more 
appropriate to you, we will make a referral upon your agreement. 
AFTER THE RESEARCH STUDY 
Participants will resume to receiving the pre-study service (if any). 
IF THE SITUATION DETERIORATES 
At any time of the service, in case of concerns about a person’s suicidal risk, or if the person is 
assessed as having moderate or higher risk of suicide, referral will be made to a hospital or Fast 
Track Clinic (FTC) for Elderly Suicide Prevention Programme (ESPP). Project Social Workers 
should also follow organization protocol for risk management and inform their service 
supervisor or a responsible staff. 
PRIVACY AND CONFIDENTIALITY 
If you consent to take part in the research your personal information may be inspected by the 
research team for purposes of analysing the results. They may also be looked at by people from 
the research team and regulatory authorities to check that the study is being carried out correctly. 
This study will obtain personal information from the Hospital Authority. Any information 
obtained in this study will remain very strictly confidential, will be known to no one who is not 
a member of the research team, and will be used for research purposes only. Participants will 
not be identified by name in any report of the completed study.  
AFTER THE STUDY 
The results of this study will be published. Preliminary findings will be included in the reports 
published by the Hong Kong Jockey Club Charities Trust. Final results will be published in 
academic publications after the entire project is completed, approximately in the year 2024. 
Participants may also obtain a copy of the study results from the research team. You will not 
be identified in any report/publication. 
FUNDING 
The Jockey Club Holistic Support Project for Elderly Mental Wellness project (JC JoyAge) is 
funded by the Hong Kong Jockey Club Charities Trust. 
RESEARCH ETHICS REVIEW 

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This study is reviewed by Institutional Review Board of the University of Hong Kong/Hospital 
Authority Hong Kong West Cluster (HKU/HA HKW IRB) and the Human Research Ethics 
Committee for Non-Clinical Faculties, the University of Hong Kong. 
RIGHTS OF RESEARCH PARTICIPANTS 
If you have any questions about the research, please feel free to contact Miss Dara Leung at 
HKU (Telephone: 3917-1758; Email: daralky@hku.hk). If you wish to know more about the 
rights as a research participant, please contact the Human Research Ethics Committee for Non-
Clinical Faculties, the University of Hong Kong (2241-5267). Thank you for taking part in this 
study. 
 
 

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Jockey Club Holistic Support Project for Elderly Mental Wellness (JC 
JoyAge) 
Service Application and Personal Data Use Consent Form 
 
SIGNATURE OF RESEARCH PARTICIPANTS 
I have read, or someone has read to me, and I understand the information provided above and 
contents explained by the social worker from _________________ (Organization). I have been 
given an opportunity to ask questions and all of my questions have been answered to my 
satisfaction. I have been given a copy of the information sheet and this form. 
 
District: _______________________________ 
 
 
 
 
 
Please tick the appropriate 
box 
 
I agree that this study obtains my personal information 
from the Hospital Authority for providing more 
appropriate services and for research purposes. 
 
□ 
I agree that the information I provided in this study can be 
used for research purposes in the future.  
 
□ 
I agree to be contacted by the research team to provide 
information about other research projects in the future. 
□ 
 
I agree this study records the course of my acceptance of 
psychological services for academic research, guidance 
and educational purposes. 
 
□ 
 
I agree this study uses my profile / event photo, film and 
sound recording, reproduced in the agency or this service 
program for communications, publications, leaflets and 
web pages. 
 
□ 
 
 
 
 
 
 
 
Name of participant 
 
Date 
 
Signature 
 
 
 
 
 
 
 
 
 
Name of person taking 
consent 
 
Date 
 
Signature