Abstract
Introduction: Optimal care of community-dwelling older persons is a global imperative. Sub-optimal care that is episodic and fragmented, is costly to the health system and can be life-threatening to the older person. As the population ages, older persons with complex needs place excessive pressure on the General Practitioner as gatekeeper to specialist medical and community supports. OPEN ARCH is an Australian-first model of care for the community-dwelling older person with complex needs. OPEN ARCH integrates care at the primary-secondary interface.
Methods: The OPEN ARCH study is a multicentre randomised controlled trial with a stepped wedge cluster design that evaluates the effectiveness of the OPEN ARCH intervention.
Eighty community-dwelling persons over 70 years of age if non-Indigenous and over 50 years of age if Indigenous were included.
The primary outcomes were Emergency Department presentations and hospital admissions. Poisson regression modelling to estimate the effectiveness. The secondary outcomes were functional independence and quality of life. Function was collected with the Functional Independence Measure and quality of life was measured with the EQ-5D-3L. Data were analysed at the cluster and participant levels.
Results: The OPEN ARCH intervention was found to not make a statistically significant difference to Emergency Department presentations or admissions. However, a stabilising of Emergency Department presentations and a trend toward lower hospitalisation rates over time was observed. Total median Functional Independence Measure score for control period assessments (median=121, IQR=116-124) was comparable to the intervention period (median=121, IQR=114-124, z=0.402, p=0.688). A similar trend was evident for EQ5D scores. When time point was added to modelling there was no difference in median Functional Independence Measure scores between the control and intervention periods. While Functional Independence Measure scores were lower at each time point, this was only significant at the fourth time point (b=-4.03, 95% CI 6.93-1.14, p=0.006), which remained after adjusting for age, Indigenous status and gender. There were no trends in EQ-5D-3L modelling.
Conclusion: Despite the lack of statistical significance, the stabilising of Emergency Department presentation rates; a trend towards lower hospitalisation rates; stabilisation of quality of life; and absence of functional decline are findings of clinical importance at the patient and service level.
Implications: OPEN ARCH is an Australian-first model of integrated are at the primary-secondary interface for community dwelling older persons with complex needs and is the only Australian-based program of its kind that has been evaluated via a randomised controlled trial. Through vertical integration at the primary–secondary interface, OPEN ARCH increases the capacity of primary care to meet the needs of this population.