Analysing sub-acute and primary health care interfaces – research in the elderly

Abstract

The National Health and Hospital Reform Commission (NHHRC)1 recommended major changes to the way services are delivered to ensure people with complex needs get appropriate and timely care in the most appropriate setting. Of particular concern is the increasing number of older people who present to the Emergency Department (ED) with multiple, interrelated medical, functional and psychosocial issues with resulting complex care needs2. In the absence of coordinated, comprehensive assessment and planning, these patients have an increased risk of deterioration in function, readmissions and unplanned institutional care3. The current system is often confusing to navigate and services are poorly coordinated across the various providers and sectors. Moreover, it is often ill-equipped to provide coordinated and integrated support needed to optimise recovery and outcome and community living. In response, the Commission reinforced the need to expand specialist services in the community, including sub-acute services, to enhance the primary and secondary care interfaces and to optimise the responsiveness of the primary health care sector to address the needs of older people who are at risk of hospital admissions.1 The rationale was to avoid inappropriate use of hospital and emergency services and to enhance integration and coordination across sectors. Following this, in 2010 the Australian Government announced an investment of $1.6 billion to deliver 1300 sub-acute beds with the goal of timely care, appropriate use of resources and better health outcomes.4 The Geriatric Evaluation and Management (GEM) model of care promotes multidisciplinary, coordinated care of older patients with multiple conditions and complex health care needs who present at the hospital emergency department.1 This geriatrician led service model aims to plan and provide medical, psychosocial and rehabilitative care tailored to the patient’s specific needs and coordinated discharge planning. Evidence indicates that a GEM model of care delivered in a dedicated ward is effective in reducing functional decline, mortality and discharge to residential aged care compared to usual care.3 However, due to system fragmentation and the complex needs of older patients following discharge, a GEM service is unlikely to significantly impact on avoidable hospital admissions unless issues at the acute, sub-acute and primary care interfaces are also identified and addressed. Patient care can be compromised during transitions between hospital and community based care because of poor integration between sectors, services and providers,5 consumers being unaware of, or unable to access services, poor communication and service gaps.6