Assessing the reach and safety of an innovative urgent care service tailored to older adults

Traditional emergency departments (EDs) are overcrowded and sometimes not suitable for older adults with complex needs. Specialised geriatric urgent care pathways for selected patients can alleviate ED demand and improve patient experience. To address urgent care needs for older adults in Southern Adelaide, the Complex And RestorativE (CARE) service was established. CARE offers alternative, geriatrician‐led treatment pathways consisting of a ward‐based treatment centre and an in‐home visiting team called Eyes on Scene (EoS). Both pathways offer medical, nursing and allied health treatment. Routinely collected clinical data were analysed to explore the reach of the service and the incidence and nature of adverse events. Between September 2021 and March 2023, the CARE service attended to 5324 older adults requiring urgent care. A significant proportion of patients were discharged to or remained in their regular place of residence, with few requiring inpatient admissions or referrals to other facilities. A total of 7% of patients required transfer to ED and adverse events were rare. The CARE service demonstrates a feasible and safe alternative model of urgent care for older Australians.

The high utilisation of emergency departments (EDs) presents a global challenge for health services. 1In Australia, the demand for emergency health care is on the rise, particularly among older adults who present at EDs with urgent but non-life-threatening conditions more frequently than other age groups. 2 Older adults frequently report negative experiences in EDs. 3 In particular, they experience long wait times and a lack of practical assistance to access food, drink and toileting facilities. 3,4Moreover, communication with staff is poor, shared decision-making is lacking, and they have a fear of staying overnight. 3Over half tive, geriatrician-led treatment pathways consisting of a ward-based treatment centre and an in-home visiting team called Eyes on Scene (EoS).Both pathways offer medical, nursing and allied health treatment.Routinely collected clinical data were analysed to explore the reach of the service and the incidence and nature of adverse events.Between September 2021 and March 2023, the CARE service attended to 5324 older adults requiring urgent care.A significant proportion of patients were discharged to or remained in their regular place of residence, with few requiring inpatient admissions or referrals to other facilities.A total of 7% of patients required transfer to ED and adverse events were rare.The CARE service demonstrates a feasible and safe alternative model of urgent care for older Australians.

K E Y W O R D S
][7] Prolonged hospitalisations carry inherent risks, and individuals remain susceptible to future readmissions after discharge. 8These challenges highlight the need for the development of care models to address the complex needs of older people who require urgent, but non-lifethreatening medical treatment.

| A potential solution
In response to the growing need for urgent care for older adults in Southern Adelaide, a novel service called the Complex And RestorativE (CARE) service has been established by the Southern Adelaide Local Health Network (SALHN) in collaboration with the Southern Australian Ambulance Service (SAAS).CARE has been designed to facilitate alternative, geriatrician-led treatment pathways with the aim of timely response, a home-first principle of care, reduced demand on the ED and improving patient experience.
The service has two pathways: a ward-based treatment centre and an Eyes on Scene (EoS) team that visits the person in their own home or residential aged care facility (RACF).Both pathways utilise telehealth technologies, and both offer timely same-day care to older adults as a substitution for the ED.Medical, nursing and allied health professionals can be accessed through both pathways.However, it should be noted that CARE cannot assess the full gamut of patients that attend a typical ED.Patients, therefore, are triaged in collaboration with the ambulance service to avoid admitting patients who have a high chance of inpatient hospital admission (e.g., those who are haemodynamically unstable or have very severe pain limiting mobility).Triage closes at 19:00 with the last patient's arrival at 19:30 as the CARE service does not routinely provide overnight facilities or visits for patients and closes at 22:00.A follow-up phone call is made to all CARE Centre and EoS patients within 24 h of treatment.On discharge, a home visit is undertaken by an allied health professional if required (Refer to Figure S1 for a detailed illustration of the CARE pathway, File S1 for the condition inclusion/ exclusion criteria and File S2 for the triage process).

| CARE centre
The centre is a six-bed treatment ward that operates independently from the ED and is located at a different site within the health network.The service is open 7 days a week 08:00-22:00.It offers on-site, timely radiology services.

| Eyes on Scene
The EoS team operates an outreach model in which staff (often a nurse or allied health professional) visit the person at home or in a RACF.All EoS patients are discussed or reviewed by a geriatrician, often via videoconference.This approach reduces the need for transportation by the ambulance and is particularly applicable for adults who reside in RACF.The service runs from 08:30 to 20:00 7 days a week.

| Eligible population
Services are accessed through dialling the ambulance on 000 (SAAS).Eligible adults include those who are 65 years or older, or 50 years or older for Aboriginal and Torres Strait Islanders and have urgent care requirements that are not life-threatening and assessed as unlikely to need an overnight stay (see File S1).

| Objectives
The service was implemented in September 2021 and is currently undergoing a comprehensive evaluation to determine outcomes for patients and for the health service.This article provides a brief overview of reach and safety.We present data from an audit of the (1) reach of the service to the intended population and (2) adverse events, including secondary transfers to ED.These factors are an important step in informing whether the program should be embedded, modified and tailored to maximise benefits and/or expanded to other Southern Australia Health sites in the future.Qualitative data regarding the acceptability of the model for service users have been published, 9 and an economic evaluation is underway.
In the context of the current new health-care service, 'reach' refers to the extent or ability of the service

Policy and Practice Impact
Expanding emergency department (ED) settings to cater to growing needs is unsustainable for older adults with complex needs.Specialised geriatric urgent care pathways offer avenues to alleviate ED demand and improve the experience for selected patients.The Complex And RestorativE (CARE) service demonstrates how alternative models of urgent care can be feasible and safe for selected older adults.
to effectively connect with and serve its intended target population or audience.It assesses how well the service reaches and engages the individuals it aims to help or support.We measure reach by exploring the number of people who access the service, the demographics of the users and the condition they were being treated for.'Safety' in the context of our research refers to the degree to which the service ensures the physical well-being of its users.It encompasses the prevention of harm through the evaluation of the occurrence of adverse events.Our findings are preliminary and future evaluations will conduct more thorough analyses about the reach and safety of the service.

| Design
In line with the SALHN Human Research Ethics Committee regulations, this work was a service evaluation and, as such, was exempt from ethical review.The project has been registered on the SALHN Quality Register (2022/ HRE00107).
Our descriptive research design presents routinely collected clinical data from the service from September 2021 to March 2023.Data include information about service use, such as the count of accepted and rejected referrals, as well as the referral source, for the entirety of the CARE service operation (8 September 2021 to 8 March 2023).We conducted more in-depth evaluation of the service (e.g., characteristics of service users) through collecting individual patient data from electronic health records for a subgroup of participants (8 September 2021 to 8 March 2022, n = 470 CARE Centre and n = 445 EoS service users).Due to the time-intensive nature of electronic health record reviews, this was not conducted for the full dataset.In this subgroup, we also report results for the FRAIL questionnaire screening tool, 10 the Global Deterioration Scale 11 (GDS) and the Barthel Index, 12 which are administered on arrival at the CARE Centre.These questionnaires are not administered to EoS patients.The FRAIL tool 10 is a short five-question assessment that evaluates fatigue, resistance, aerobic capacity, illnesses and weight loss in patients.Based on these results, patients are categorised into three groups: robust (score = 0), prefrail (score = 1-2) and frail (score = 3-5).The GDS 11 was used to measure cognitive function.It consists of seven stages, with stages 1-3 representing predementia stages and stages 4-7 representing dementia stages.In stage 5 and beyond, individuals require 24/7 assistance.Each stage in the GDS is assigned a number, a short title (e.g., forgetfulness) and a brief description of the characteristics associated with that stage.The Barthel Index 12 is a tool used to assess an individual's ability to perform activities of daily living.The index measures the individual's performance in 10 areas such as feeding and bathing.The scoring of the Barthel Index ranges from 0 to 100, with 100 representing complete independence.

| RESULTS
Tables 1 and 2 provide descriptive data regarding the CARE Centre and the EoS services spanning the entire duration of their operation, from 8 September 2021 to 8 March 2023.A total of 5324 patients were treated by these two services over the 2-year period for a variety of urgent care presentations.Nine adverse events occurred, with two resulting in harm to either the patient or the organisation, while the remaining seven had no harmful consequences.
Tables 3 and 4 provide details about the demographic characteristics of the sub-sample of accepted patients at the CARE centre and EoS service, respectively.The average age for patients using both services was in the mid-80s.Only one individual identified as Aboriginal or Torres Strait Islander.One-quarter of the CARE service users resided in RACF, while over half (61%) of the EoS service users lived in RACF.The patients living in the community were on average younger, less frail and had better function (as measured on the Barthel index).

| DISCUSSION
With rapidly increasing demand, the conventional approach to providing emergency health care may not be sustainable or suitable for older adults who often have complex physical and social requirements. 1,12Tailored urgent care pathways for older people present new opportunities to reduce the strain on EDs and enhance the overall patient experience. 1,2The newly implemented CARE service has addressed concerns raised by older adults themselves [3][4][5] including the incorporation of geriatric-trained multidisciplinary staff and the adoption of person-centred care approaches.The CARE model addresses the adverse aspects of the ED environment often expressed by older adults, including noise, staff business, lengthy wait times and uncomfortable seating, by providing patient treatment in either a dedicated, well-designed geriatric ward or within the comfort of their own homes. 9A follow-up phone call or home visit postdischarge was also undertaken with the aim to improve outcomes and patient experience. 13,14he reach of the model proved effective in redirecting the urgent care requirements of selected older adults away from the ED, with a total of 5324 patients treated over a span of 2 years.Seventy per cent of the CARE Centre referrals were accepted after triage: the primary reason for rejection was the patient needing sub-speciality treatment that the service could not provide.Approximately 70% of CARE Centre referrals were attributed to musculoskeletal issues (such as falls), decline in function and pain, ranking them as the top three reasons for referral.Seventythree per cent of patients admitted to the CARE Centre underwent medical imaging, suggesting that prompt access to imaging is important.The services target demographic were individuals aged 65 and above.The average age of the patients was in the mid-80s, but the service also extended its care to younger and older individuals.Both men and women accessed the service, but women presented more frequently to both the CARE Centre and EoS.Individuals who accessed the CARE Centre tended to live in their own homes, whereas the reverse was seen for EoS where the majority of patients resided in RACF.The reach of the service to Aboriginal and Torres Strait Islander individuals was limited.Our research group is in the process of organising yarning circles with Indigenous peoples to better understand their needs and preferences for urgent care.
Considering the volume of service users, the overall count of adverse events was remarkably minimal, underscoring the service's commitment to safety.Over the two services, most patients were discharged or remained in their usual place of residence with few hospital admissions (<12%) or onward referrals (1%).Only 7% of patients required up-transfer to the ED, and there were negligible adverse events, suggesting that the care model is safe for treating urgent conditions in older adults.Representation rates to a local ED after discharge from the CARE Centre was 22%.This figure is in line with previous research exploring return visits of older adults to emergency services, 15,16 potentially due to comorbidities, polypharmacy and barriers to accessing primary care. 17wing to constraints imposed by the health services' electronic reporting system, elucidating the behind patients' subsequent visits to the ED was not possible.Nevertheless, this unexplored domain presents an area for further investigation.The analysis of routinely collected clinical data for auditing a new hospital service revealed challenges related to the hospital's limited electronic medical record system and the presence of missing data.Additionally, relying on hospital staff to keep records in a busy work environment with competing demands resulted in significant gaps in data.These common issues 18 underscore the need for improved technology infrastructure and enhanced data recording practices to ensure more reliable and robust audits in the future.

| CONCLUSION
In summary, the innovative urgent care pathway allowed a subgroup of triaged older adults to bypass ED and receive timely and person-centred care, demonstrating its usefulness.Over a span of 24 months, the service attended to a cohort exceeding 5000 individuals, with notable usage by people in their mid-80s, although younger and older people were also treated.Both women and men accessed the service for a wide spectrum of medical conditions, with musculoskeletal interventions, including those related to falls, being the predominant presentation.The safety of the service is evidenced through the exceedingly low incidence of adverse events.Based on the initial findings and favourable acceptability data, 9 there is a strong indication that implementing this care model in other Australian health facilities could yield positive outcomes.The CARE Centre is dedicated to ongoing development and is currently implementing geriatric trauma pathway.This pathway aims to provide patients with evidence-based care following their experience of 'silver trauma', which predominantly involves falls from heights less than two metres.Using a continuous improvement methodology, a comprehensive evaluation of the impact on older people and the health system will be conducted, and the findings will be subsequently published.

ACKNO WLE DGE MENTS
Thank you to Jodie Gardner and Jo Preston who assisted with providing administrative data for the research.Open access publishing facilitated by Flinders University, as part of the Wiley -Flinders University agreement via the Council of Australian University Librarians.

FUNDING INFORMATION
Comprehensive descriptive data for the Complex And RestorativE (CARE) Centre spanning the entire duration of its operation, from 8 September 2021 to 8 March 2023.Examples of outpatient services include services such as the Southern Adelaide Local Health Network (SALHN) and The Geriatric Evaluation and Management (GEM)@Home service.
T A B L E 1Note: Comprehensive descriptive data for the Eyes on Scene (EoS) service spanning the entire duration of its operation, from 8 September 2021 to 8 March 2023.Sub-sample of patient data for accepted referrals at the Complex And RestorativE (CARE) Centre from 8 September 2021 to 8 March 2022 (n = 470; 19%).
T A B L E 2 This project is funded by the Australian Government 2022 Medical Research Future Fund Models of Care to Improve the Efficiency and Effectiveness of Acute Care Grant (2018573).CONFLICT OF INTEREST STATEMENT Professor Crotty, Associate Professor Whitehead and Professor Kate Laver have dual roles with Flinders University and Southern Adelaide Local Health Network.Sub-sample of patient data for accepted referrals at the Eyes on Scene (EoS) service from 8 September 2021 to 8 March 2022 (n = 445; 16%).Although the service has an age criterion of 65 years or older, or 50 years or older for Aboriginal and Torres Strait Islanders, the CARE service will treat any individual who requires geriatric care.Individuals who are younger than 50 often have young-onset dementia and reside in a residential aged care facility (RACF).
T A B L E 4Note: