1. An introduction
The way the Australian health care system manages people in the last few years of life is clinically and economically misaligned, often delivering a poor experience to patients and their families.


2. Short description of practice change implemented
Implement a networked care model that aims to be comprehensive, person centred, and integrates health with social care, and clinic with community care.


3. Aim and theory of change
To develop an evidence based new model of care which aims to redress the clinical and economical misalignment by integrating health and social care, reducing hospitalisations and improving client experience.


4. Targeted population and stakeholders
The service is designed for clients that are over 65, live in the community, reside in metropolitan Perth, have two or more chronic conditions and have had between one and five hospital admissions in a year.


5. Timeline
The service has been developed over the past 2 years


6. Highlights
A peri-end-of-life service branded Integrum Aged Care+ has been co-designed with McKinsey and Co, based on feedback from key stakeholders and with support from WA Primary Health Alliance (WAPHA). The dedicated service integrates medical and non-medical health and social care services to deliver care in the community as opposed to within the hospital setting. Clients receive a high level of case management from a registered nurse focused on the co-ordination and monitoring of health and social care needs, supported by a multidisciplinary team.

As part of the intervention, new technologies are being deployed including active in-home monitoring and video technologies that puts the client at the forefront of the telemedicine experience.


7. Comments on sustainability
The services financial model has been designed to result in a financial breakeven point within the first three years, utilising existing funding mechanisms.


8. Comments on transferability
Whilst initially developed in Western Australia, the model has commenced implementation in South Australia. It is also thought that it could be used in place of Health Care Homes.


9. Conclusions
This initiative is an integral part of testing a technologically enabled alternative networked care model for people with complex conditions in the last years of life where health and aged care models intersect.

The service has undergone a qualitative evaluation of the client experience by Curtin University; and an economic evaluation by PricewaterhouseCoopers (PwC) which measures hospitalisations against a control group. Initial results indicate a marked reduction in hospitalisations and improved client experience. The results have been requested by the Royal Commission into Aged Care Quality and Safety for consideration into their recommendations.


10. Discussions
This model has been noted within the WA Sustainable Health Review and the Royal Commission into Aged Care Quality and Safety as an option to improve aged health care in Australia.


11. Lessons learned
Key lessons have been that clients have good access to Primary Health Care however coordination and integration of care is lacking, which is where this model has potential to strengthen the existing system and improve outcomes for clients.

Introduction:
Increasing numbers of older people are having surgery, with high rates of postoperative morbidity and mortality. Integration of perioperative medicine services with primary care offers an opportunity for early implementation of evidence-based preoperative optimisation. This proactive approach may reduce downstream burden on the health system in terms of sequelae from postoperative complications, and is expected to improve patient outcomes.

Aims:
To evaluate enablers and barriers to primary care engagement in preoperative optimisation;
To co-produce a strategy for primary care-led, integrated preoperative optimisation of older patients.

Methods:
Stakeholder interviews with 38 clinicians and professionals explored enablers and barriers to integration of primary and secondary care services in preoperative optimisation of older people. Interviews revealed themes, used to develop a survey validated by 12 expert raters.
A purposive sampling frame was developed, to deliver generalisability of practice size (compared with NHS Digital data) and geographic spread. A bimodal strategy for survey distribution was employed to maximise response rate, using paper surveys at primary practice meetings where this fit within the predetermined sampling frame.

Results:
Stakeholder interviews revealed:
Barriers:
- low volume of referrals to surgery per GP
- unclear referral pathways
- Unclear roles
- lack of education
- time restraints
Enablers:
- Frailty a priority for GPs
- appetite for genuine integration
- recognition of surgery as a high risk period
Interim results of survey (closing July 14):
Enablers:
- 85% of GPs believe preoperative optimisation improves postoperative outcomes
- 49% of GPs feel that they could identify potentially modifiable risk factors
- 81% of GPs feel it is the role of primary care to discuss modifiable risk factors with patients
Barriers:
- 52% of GP’s had referred zero or 1 patient (>65yo) to a surgical specialty in the past month
- 12% of GP’s felt they had adequate to deliver preoperative optimisation
- 55% of GP’s were not aware of having access to perioperative medicine services

Discussion and conclusion:
As increasing numbers of older people are having surgery, with high levels of multimorbidity and frailty, there is an escalating need for whole-system integrated surgical pathways designed to handle patient complexity.
The first phase of this quality improvement initiative identified a need in primary care for education and access pathways, to build cross-sector relationships and upskill clinicians in order to create an environment within the workforce that will be receptive to formalised integrated perioperative medicine services.

Lessons learned
Relational factors are key to developing integrated pathways fit for purpose. Work is needed to build cross-sector clinical relationships that complement structural and organisational changes.

Limitations
Survey findings are limited by a response rate of 30% (interim analysis). This is the expected response rate for a survey of primary care. This likely results in an underestimate of key findings, as clinicians with an interest in perioperative medicine are more likely to have responded.

Future research
Next steps include co-production of a multidisciplinary educational workshop with local primary care practices, and co-development of a primary care to POPS e-referral and communication pathway.

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.

1. Frailty is a common syndrome affecting 25% of the population aged 70+ in Australia, equating to approximately 26,000 people residing in Northern Sydney. People living with frailty have 2-3 times the healthcare utilisation and poorer outcomes in hospital compared to their non-frail counterparts.
2. Sydney North Health Network is working collaboratively with Northern Sydney Local Health District, health professionals and consumers, to co-design and implement targeted interventions to identify and reduce frailty, avoid inappropriate hospital admissions and improve health outcomes for our elderly population. Phase one includes delivery of education and support to health professionals, to increase understanding and implementation of:
• The concept of frailty
• Appropriate screening using the FRAIL scale
• Preventive and reablement management plans in primary care.
This included consultation with clinicians and consumers to understand existing knowledge and screening practices, co-design of resources, including protocols to support handover of care and development of pathways to support appropriate referral and management.
Phase two will identify service gaps in the community and develop a co-commissioning strategy to shape service delivery to meet local need.
3. Implement recommendations from the Asia Pacific Clinical Practice Guidelines for the Management of Frailty.
4. The target populations for phase one are health professionals from primary care, community and acute settings.
5. Phase one, 2 years. Phase two, 3-years.
6. Education and awareness events were implemented in both settings:
- 82 LHD health professionals and 79 general practice and allied health professionals have participated to date.
- 53 general practices have received intensive, in-practice training on use of FRAIL scale and resources available to help them navigate service and management options.
A trial of screening has been implemented in 2 acute hospitals. Screening of 387 patients identified high prevalence of frailty and pre-frailty (82-93%)
Screening results and management plans have been included in patient discharge summaries to improve handover to primary care.
7. Primary care is most likely the more appropriate setting to continue screening on an ongoing basis and likely to yield more sustainable, long term results, particularly on hospital avoidance.
8. This framework includes a multi-disciplinary team approach to care and encourages screening at any point during the patient journey, in any care setting.
9. Screening for frailty and implementing management plans to improve patient outcomes is possible in both the inpatient and community setting.
Further data is required in primary care to measure impact and outcomes.
10 & 11. Hospital screening is feasible, but capacity for intervention is limited. With some patients receiving appropriate intervention in hospital, aiming to prevent deterioration, analysis in progress will confirm impact and gaps.
A vendor has been engaged to develop a screening app that integrates with GP clinical software systems, to support data collection in primary care.
Next steps include:
- development and implementation of primary care data app
- follow up with general practices, to gauge acceptance of interventions and tools provided
- utilise data from screening and mapping of community services to inform development of commissioning strategy.