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

Abstract

\n 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.