This project evaluates the Jockey Club SO.ME.CARE Carer Support Project, a three-year social–medical collaborative intervention for high-risk older patients discharged from Tai Po and Alice Ho Miu Ling Nethersole Hospitals and their family carers. Using screening-guided triage, caregivers receive risk-stratified, carer-centred interventions ranging from workshops to intensive casework and CareCher peer support. Outcomes focus on caregiving competence, caregiver health, quality of life, mental wellbeing, and reduced hospital readmissions.