The Older Persons Enablement And Rehabilitation for Complex Health conditions (OPEN ARCH) model of care intervention extends the GEM model of care and enables a direct path from General Practitioners (GP) to a community based geriatrician for comprehensive interdisciplinary assessment and care management. OPEN ARCH then facilitates timely access to the most appropriate care in the community that if provided early, could enable the older person’s health to be supported such that they can remain living in the community and not require hospital attendance or admission.
The intervention is targeted and focused and will deliver better integrated care for community-dwelling people with complex conditions through systemised integration of primary and secondary care. This will involve comprehensive assessment, care coordination and management by co-located, community-facing specialist geriatric and primary care services and early identification and intervention for people at risk of imminent functional decline or hospitalisation.
General Practitioners (GPs) will identify high risk consumers and can refer to the specialist geriatric “hot clinic” for comprehensive assessment. Following specialist geriatric assessment, the client will engage with an Enablement Officer whose role it will be to co-ordinate those recommendations made from assessment via referral to relevant existing primary healthcare services. The OPEN ARCH project team is formed via a partnership between the Cairns and Hinterland Hospital and Health Service, Torres and Cape Hospital and Health Service and the North Queensland Primary Health Network (NQPHN).