Older persons enablement and rehabilitation for complex health conditions (OPEN ARCH)

Initiative Type
Model of Care
11 September 2017
Last updated
22 February 2023


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).

OPEN ARCH Program | Integrated Care Innovation Fund from Clinical Excellence Division on Vimeo.

Key dates
Jan 2016
Feb 2019
Implementation sites
Cairns and Hinterland Hospital and Health Service
Healthcare Improvement Unit, Northern Queensland PHN, Brisbane North PHN


Improve quality of care and reduce avoidable hospital demand for people with complex conditions who are at risk of presenting to hospital.

To address health and social needs in a preventative model that supports the older person.


  • Specialist geriatric assessment care planning collocated with General Practice
  • Sustained reduction in ED presentations, hospital admissions and in-patient bed days


The Integrated Care Innovation Fund provides financial support to innovative projects that deliver better integration of care, address fragmentation in services and provide high-value healthcare. Funded projects also demonstrate a willingness to embrace and encourage the uptake of new technology alongside the benefits of integrating care and improving communication between health care sectors.

Solutions Implemented

The initiative has two components:

  1. Fast track specialist geriatric assessment, care planning and coordination in the community for frail older people with complex conditions; and
  2. An early intervention service for clients with complex conditions at risk of hospitalisation or significant deterioration.

The OPEN ARCH intervention is built on four values of quality integrated care:

  • preventative health care provided closer to home
  • alignment of specialist/generalist care
  • care coordination and enablement
  • primary care capacity building


Evaluation and Results

  • 63% increase in allied health interventions that restore function and improve independence
  • 54% increase in the utilisation of supports required to continue living at home
  • Improved quality of life among participants
  • Reduced hospital length of stay among admitted participants
  • Improved timeless of geriatric intervention and reduced duplication of assessment
  • Establishment of seamless pathways between health and aged care systems

Lessons Learnt

Primary care is central to the sustainability of high-quality care solutions for the older person, and the needs of this stakeholder must be explored and addressed for model success.

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Key contact

Eddy Strivens
Clinical Director
Cairns and Hinterland Hospital and Health Service
(07) 4226 6197