Does a Community Care programme reach a high health need population and high users of acute care hospital services in Melbourne, Australia? An observational cohort study.

Objective: The Community Care programme is an initiative aimed at reducing hospitalisations and emergency department (ED) presentations among patients with complex needs. We aimed to describe the characteristics of the programme participants and identify factors associated with enrolment into the programme.

Design: This observational cohort study was conducted using routinely collected data from the National Centre for Healthy Ageing data platform.

Setting: The study was carried out at Peninsula Health, a health service provider serving a population in Melbourne, Victoria, Australia.

Participants: We included all adults with unplanned ED presentation or hospital admission to Peninsula Health between 1 November 2016 and 31 October 2017, the programme's first operational year.

Outcome Measures: Community Care programme enrolment was the primary outcome. Participants' demographics, health factors and enrolment influences were analysed using a staged multivariable logistic regression.

Results: We included 47 148 adults, of these, 914 were enrolled in the Community Care programme. Participants were older (median 66 vs 51 years), less likely to have a partner (34% vs 57%) and had more frequent hospitalisations and ED visits. In the multivariable analysis, factors most strongly associated with enrolment included not having a partner (adjusted OR (aOR) 1.83, 95% CI 1.57 to 2.12), increasing age (aOR 1.01, 95% CI 1.01 to 1.02), frequent hospitalisations (aOR 7.32, 95% CI 5.78 to 9.24), frequent ED visits (aOR 2.0, 95% CI 1.37 to 2.85) and having chronic diseases, such as chronic pulmonary disease (aOR 2.48, 95% CI 2.06 to 2.98), obesity (aOR 2.06, 95% CI 1.39 to 2.99) and diabetes mellitus (complicated) (aOR 1.75, 95% CI 1.44 to 2.13). Residing in aged care home and having high socioeconomic status) independently associated with reduced odds of enrolment.

Conclusions: The Community Care programme targets patients with high-readmission risks under-representation of individuals residing in residential aged care homes warrants further investigation. This study aids service planning and offers valuable feedback to clinicians about programme beneficiaries.