Objective: The evaluation of a new model of care for older people with complex health care needs that aimed to reduce their use of acute hospital services. Method:Older people (over 55 years) with complex health care needs, who had made three or more presentations to a hospital emergency department (ED) in the previous 12 months, or who were identified by community health care agencies as being at risk of making frequent ED presentations, were recruited to the project. The participants were allocated a "care facilitator" who provided assistance in identifying and accessing required health care services, as well as education in aspects of self management. Data for the patients who had been participants on the project for a minimum of 90 days (n = 231) were analysed for their use of acute hospital services (ED presentations, admissions and hospital bed-days) for the period 12-months pre-recruitment and postrecruitment. A similar analysis on the use of hospital services was conducted on the data of patients who were eligible and who had been offered participation, but who had declined (comparator group; n = 85).Results: Post recruitment, the recruited patients displayed a 20.8% reduction in ED presentations, a 27.9% reduction in hospital admissions, and a 19.2% reduction in bed-days. By comparison, the patients who declined recruitment displayed a 5.2% increase in ED presentations, a 4.4 % reduction in hospital admissions, and a 15.3% increase in inpatient bed-days over a similar timeframe. Conclusion

Background Older people with multiple chronic conditions and complex health care needs require a comprehensive, accessible and well-coordinated system of services. To address this growing problem, a consortium of acute and community-based health care organisations implemented a ‘Patients First’ model of service integration for the target population. The project evaluation utilised a combination of quantitative and qualitative methods in an action research framework. Findings The evaluation process not only demonstrated the benefits of the project to patients and the health care system, but also contributed to the identification of pivotal components in the model, aspects requiring attention and consequently their refinement. It was also a vehicle for the development of a sense of ownership amongst staff and has evolved into an integral part of the model.