OPEN ARCH: A model of integration for the older person with complex needs

Introduction (comprising context and problem statement): Older persons with complex needs experience frequent and repeated health care interactions, have longer hospital stays and are more likely to require formal supports to continue living at home. They are also  vulnerable to system complexities which can be costly to the health system and life threatening to the individual.  To avoid preventable hospitalisation and premature institutionalisation, these older people  require comprehensive, patient-focussed medical and social supports Short description of practice change implemented: OPEN ARCH (Older Persons Enablement and Rehabilitation for Complex Health Needs) is a co-designed integrated care program delivered at the primary-secondary interface. OPEN ARCH provides preventative focussed multidisciplinary comprehensive geriatric assessment, and social care coordination for older persons at risk of functional decline or hospitalisation. Aim and theory of change: OPEN ARCH aims to improve access to comprehensive care for the older person that is otherwise only available through hospital admission.  Evidence suggests that engagement with primary care and improved access to specialist health care and preparatory social supports early in the trajectory of the person’s illness can prevent avoidable hospitalisation and assist the older person to stay living at home for longer.  Targeted population and stakeholders: Older persons with complex needs who are at risk of rapid functional decline or hospitalisation are eligible for referral to OPEN ARCH.  OPEN ARCH is a Queensland Health service with formal service partnerships with primary care practitioners in Far North Queensland.  Timeline: OPEN ARCH commenced in November 2017 and continues to provide services to older persons across the Cairns region. Highlights (innovation, Impact and outcomes):  OPEN ARCH is an Australian-first model of care that combines specialist outreach, care coordination and primary care partnership for the provision of comprehensive care for the older person. Comments on sustainability:  The financial sustainability of OPEN ARCH is leveraged from the revenue opportunities for primary and specialist care provision.  While sustainability of care coordination is challenging in the Australian health system, the OPEN ARCH model is sustained through the primary-secondary partnership and collaboration with social care agencies. Comments on transferability: Primary-secondary collaboration and the establishment of common objectives of integration are essential for successful geographic or demographic transferability. Conclusions (comprising key findings):  Preliminary results indicate that OPEN ARCH has a positive impact on quality of life for the older person and is a model acceptable to the client and other key stakeholders. Shared medical records, case conferencing and complementary provision of specialist-generalist services is supportive of a patient focussed model of care. Discussions: The OPEN ARCH model of care achieved integration through the consideration of many core components of integrated care, namely: a targeted approach for older persons with complex needs; utilisation of primary care financial incentives; shared medical records; a collaborative culture; effective leadership. Lessons learned: Vertical integration within the health system is achievable yet sectoral integration beyond a care co-ordination model is challenging.