OPEN ARCH: integrated care at the primary-secondary interface for the community-dwelling older person with complex needs.

Abstract

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.