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

Optimal care of community-dwelling older Australians with complex needs is a national imperative. Suboptimal care that is reactive, episodic and fragmented, is costly to the health system, can be life threatening to the older person and produces unsustainable carer demands. Health outcomes would be improved if services (health and social) are aligned towards community-based, comprehensive and preventative care. Integrated care is person-focussed in outlook and defies a condition-centric approach to healthcare delivery. Integration is a means to support primary care, with the volume and complexity of patient needs arising from an ageing population. Older Persons Enablement and Rehabilitation for Complex Health Conditions (OPEN ARCH) is a targeted model of care that improves access to specialist assessment and comprehensive care for older persons at risk of functional decline, hospitalisation or institutionalised care. OPEN ARCH was developed with primary care as the central integrating function and is built on four values of quality care: preventative health care provided closer to home; alignment of specialist and generalist care; care coordination and enablement; and primary care capacity building. Through vertical integration at the primary–secondary interface, OPEN ARCH cannot only improve the quality of care for clients, but improves the capacity of primary care to meet the needs of this population.

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Impact of an Integrated Community-based Model of Care for Older People with Complex Conditions on Hospital Emergency Presentations and Separations: A Step-wedged Randomized Trial

10.21203/rs.3.rs-265117/v1 ◽

2021 ◽

Author(s):

Mann Jennifer ◽

Fintan Thompson ◽

Robyn McDermott ◽

Adrian Esterman ◽

Edward Strivens

Keyword(s):

Older People ◽

Controlled Trial ◽

Community Dwelling ◽

Ageing Population ◽

Significant Finding ◽

Older Person ◽

Complex Needs ◽

Significant Difference ◽

The Impact ◽

Open Arch

Abstract BackgroundAn ageing population and rise in multi-morbidity increase hospital utilisation and acuity of presentation, particularly amongst the older person with complex needs. Health systems must reorient towards preventative and co-ordinated care to reduce hospital demand and achieve positive and fiscally responsible client outcomes. Integrated care models can improve outcomes for the older person by aligning primary practice with the specialist health care and social services required to manage complex needs. This paper describes the impact of a community facing program that integrates care at the primary-secondary interface on the rate of Emergency Department (ED) presentation and hospital separations amongst older people with complex needs.MethodsThe OPEN ARCH study is a multicentre randomised controlled trial with a stepped wedge cluster design. General practitioners (GPs; n=14) are considered ‘clusters’ each comprising a mixed number of participants. 80 community dwelling persons over 70 years of age if non-Indigenous and over 50 years of age if Indigenous were included in the study. Clusters were randomly assigned to the time at which they would commence the OPEN ARCH intervention, with intervention periods of 3, 6 and 9 months duration. Each participant was its own control. ED presentations and hospital separations were collected from Queensland Health Casemix data and analysed with multilevel mixed-effects Poisson regression modelling to determine the effectiveness of the OPEN ARCH intervention. Data were analysed at the cluster and participant levels.ResultsThe OPEN ARCH intervention was found to not make a statistically significant difference to ED presentations or hospitalisations. However, a stabilising of ED presentations and trend toward lower hospitalisation rates over time was observed. ConclusionsWhile this study detected no statistically significant different change in ED presentations or hospital separations, a plateauing of ED presentation and hospitalisation ratesis a clinically significant finding for older persons with complex needs. Multi-sectoral integrated programs of care require an adequate preparation period and sufficient duration of intervention for effectiveness to be measured. Trial registrationThe OPEN ARCH study received ethical approval from the Far North Queensland Human Research Ethic Committee, HREC/17/QCH/104 – 1174 and is registered on the Australian and New Zealand Trials Registry, ACTRN12617000198325p.

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Impact of an integrated community-based model of care for older people with complex conditions on hospital emergency presentations and admissions: a step-wedged cluster randomized trial

BMC Health Services Research ◽

10.1186/s12913-021-06668-x ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Jennifer Mann ◽

Fintan Thompson ◽

Robyn McDermott ◽

A. Esterman ◽

Edward Strivens

Keyword(s):

Older People ◽

Older Persons ◽

Hospital Admissions ◽

Community Dwelling ◽

Trial Registration ◽

Significant Finding ◽

Complex Needs ◽

Primary Practice ◽

The Impact ◽

Open Arch

Abstract Background Health systems must reorient towards preventative and co-ordinated care to reduce hospital demand and achieve positive and fiscally responsible outcomes for older persons with complex needs. Integrated care models can improve outcomes by aligning primary practice with the specialist health and social services required to manage complex needs. This paper describes the impact of a community-facing program that integrates care at the primary-secondary interface on the rate of Emergency Department (ED) presentation and hospital admissions among older people with complex needs. Methods The Older Persons Enablement and Rehabilitation for Complex Health Conditions (OPEN ARCH) study is a multicentre randomised controlled trial with a stepped wedge cluster design. General practitioners (GPs; n = 14) in primary practice within the Cairns region are considered ‘clusters’ each comprising a mixed number of participants. 80 community-dwelling persons over 70 years of age if non-Indigenous and over 50 years of age if Indigenous were included at baseline with no new participants added during the study. Clusters were randomly assigned to one of three steps that represent the time at which they would commence the OPEN ARCH intervention, and the subsequent intervention duration (3, 6, or 9 months). Each participant was its own control. GPs and participants were not blinded. The primary outcomes were ED presentations and hospital admissions. Data were collected from Queensland Health Casemix data and analysed with multilevel mixed-effects Poisson regression modelling to estimate the effectiveness of the OPEN ARCH intervention. Data were analysed at the cluster and participant levels. Results Five clusters were randomised to steps 1 and 2, and 4 clusters randomised to step 3. All clusters (n = 14) completed the trial accounting for 80 participants. An effect size of 9% in service use (95% CI) was expected. The OPEN ARCH intervention was found to not make a statistically significant difference to ED presentations or admissions. However, a stabilising of ED presentations and a trend toward lower hospitalisation rates over time was observed. Conclusions While this study detected no statistically significant change in ED presentations or hospital admissions, a plateauing of ED presentation and admission rates is a clinically significant finding for older persons with complex needs. Multi-sectoral integrated programs of care require an adequate preparation period and sufficient duration of intervention for effectiveness to be measured. Trial registration The OPEN ARCH study received ethical approval from the Far North Queensland Human Research Ethics Committee, HREC/17/QCH/104–1174 and is registered on the Australian and New Zealand Trials Registry, ACTRN12617000198325p.

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Beyond multimorbidity: primary care and the older person with complex needs

Australian Journal of Primary Health ◽

10.1071/py20125 ◽

2021 ◽

Author(s):

Jennifer Mann ◽

Fintan Thompson ◽

Rachel Quigley ◽

Robyn McDermott ◽

Susan Devine ◽

...

Keyword(s):

Primary Care ◽

Older Person ◽

Complex Needs

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Much Ado About Fried Chicken: Abetting Aspiration or Respecting Autonomy?

American Journal of Speech-Language Pathology ◽

10.1044/2019_ajslp-18-0207 ◽

2019 ◽

Vol 28 (3) ◽

pp. 1356-1362

Author(s):

Laurence Tan Lean Chin ◽

Yu Jun Lim ◽

Wan Ling Choo

Keyword(s):

Palliative Care ◽

End Of Life ◽

Multidisciplinary Team ◽

Biopsychosocial Model ◽

Family Members ◽

Clinical Decisions ◽

Goals Of Care ◽

Complex Needs ◽

Aspiration Risk ◽

Patient Centric

Purpose Palliative care is a philosophy of care that encompasses holistic, patient-centric care involving patients and their family members and loved ones. Palliative care patients often have complex needs. A common challenge in managing patients near their end of life is the complexity of navigating clinical decisions and finding achievable and realistic goals of care that are in line with the values and wishes of patients. This often results in differing opinions and conflicts within the multidisciplinary team. Conclusion This article describes a tool derived from the biopsychosocial model and the 4-quadrant ethical model. The authors describe the use of this tool in managing a patient who wishes to have fried chicken despite aspiration risk and how this tool was used to encourage discussions and reduce conflict and distress within the multidisciplinary team.

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