In line with Sláintecare (2017) and the Department of Health's Capacity review (2018), a shift in healthcare service provision is now required to place the focus on integrated, person-centred care, based as close to home as possible.
In order to enable this, the Integrated Care Programme for the Prevention and Management of Chronic Disease (ICPCD) is supporting the national implementation of a model of integrated care for the prevention and management of chronic disease as part of the Enhanced Community Care Programme (ECC).
The Model of Care for the Integrated Prevention and Management of Chronic Disease has a particular focus on preventive healthcare, early intervention and the provision of supports to live well with chronic disease.
The investment in the ECC programme will be delivered on a phased basis with a view to national coverage being achieved within a two- to three- year period.
Three priority areas have been identified as follows:
Structural reform of healthcare delivery within the community with Community Health Networks (CHNs) becoming the basic building blocks for the organisation, management and delivery of community services across the country; Creating Specialist Ambulatory Care Hubs within the community to support primary care management of chronic disease and older people with complex needs; and, Scaling Integrated Care for Older People and Chronic Disease through the recruitment of specialist integrated care teams including Frailty at the Front Door and COPD Outreach Teams. The focus is on providing an end-to-end pathway that will reduce admissions to acute hospitals by providing access to diagnostics and specialist services in the Specialist Ambulatory Care Hubs in a timely manner.
For service users who require hospital admission, the emphasis is on minimising the hospital length of stay, with the provision of post-discharge follow up and support for people in the community and in their own homes, where required.
A shared local governance structure across the local acute hospitals and the associated CHO will ensure the development of a fully integrated service and end-to-end pathway for individuals living with chronic disease.
The ECC Programme is underpinned by a set of key principles including:
Eighty percent of services delivered in Primary Care are through the GP and CHNs; Identifying and building health needs assessments at a CHN level (approximate population of 50,000) based on a population stratification approach to include identification of people with chronic disease and frequent service users, thereby ensuring the right people get the right service based on the complexity of their health care needs; Utilisation of a whole system approach to integrating care based on person centred models, while promoting self-care in the community; The Older Persons and Chronic Disease Service Models set out an end to end service architecture for the identification and management of frail older adults with complex care needs and people living with chronic disease; Learning from, and delivering services, based on best practice models and the extensive work of the integrated care clinical programmes to date, particularly in the areas of Older Persons and Chronic Disease; Embed preventive approach to chronic disease into all services; Availability of a timely response to early presentations of identified conditions and the ability to manage appropriate levels of complexity related to same in the community; Resources applied intensively in a targeted manner to a defined population, implementing best practice models of care to demonstrate the delivery of specific outcomes and sustainable services; and, The need to frontload investment, coupled with reform to strengthen community services. Specialist Ambulatory Care Hubs are sites identified outside of the hospital setting that will provide access to specialist services within the community.
Each hub will be affiliated with a local hospital and will serve a population of approximately 150,000 and will focus primarily on the prevention and management of chronic diseases.
These hubs will be established to support the provision of care closer to home and to facilitate ready access to diagnostics, specialist services and specialist opinions in order to enhance the delivery of individual-centred care, support early intervention and avoid hospital admission, where possible.
Each site will develop a suite of pathways that provide access to the hubs and to diagnostics including spirometry, radiology and laboratory testing.
The integrated care services will receive clinical governance from dedicated Specialist Consultants to ensure the provision of the right care, in the right place, at the right time.
The Integrated Respiratory Service will support:
• A holistic, multidisciplinary approach to the care of individuals with COPD and/or Asthma
• Provision of a reformed outpatient service that utilises telehealth and other ICT measures to facilitate a more effective and efficient delivery of care
• Reduced waiting times for service users for hospital-based outpatient services
• Timely access to specialist services and specialist opinion for service users with COPD and/or Asthma
• Early intervention pathways/urgent access clinics for acute, chronic or newly presenting COPD and/or Asthma
• Development of pathways for the management of COPD and Asthma
• The early assessment and implementation of COPD and Asthma pathways that will support GP-led primary care, efficient discharge back to the community where appropriate and reduce the need for repeated hospital-based outpatient reviews
• Provision of oversight and implementation of self-management support services for COPD and/or Asthma including PR
• Facilitating access and reporting of non-invasive respiratory testing e.g.
spirometry
• Providing improved integration of early discharge, outreach and potentially admission avoidance programmes
• Developing and managing oxygen assessment and review clinics under the governance of the Integrated Respiratory Consultant (or specified other Respiratory Consultant until Integrated Respiratory Consultant is in post).
Pulmonary Rehabilitation (PR) has been proven to increase exercise capacity and health status in people with COPD and/or Asthma who have significant self-reported exercise limitation.
It can improve exercise capacity in people with a variety of respiratory diseases that affect activities of daily living.
The role of the CNS Respiratory - Pulmonary Rehabilitation (PR) Integrated Care will differ according to the needs and configuration of established integrated respiratory services at each site.
The successful candidate will work within the Specialist Ambulatory Care Hub PR service and integrate with other Specialist Ambulatory Care Hub services between the hospital and community.
They will work with colleagues across these services to develop and implement ambulatory care pathways to manage service users with COPD and/or Asthma and associated co-morbidities, within the community setting.
The post holder will function as part of a team providing seamless patient-centred integrated care within an Integrated Respiratory Service (acute integrated respiratory services and integrated community based respiratory services) along with other agencies to deliver effective evidenced based care.
The post holder will have a close working relationship with the Respiratory Integrated Care and COPD Outreach services as part of an overarching Integrated Respiratory service and will work as part of a multidisciplinary team delivering coordinated evidence based care for service users in primary care whilst liaising closely with secondary care.
They will also liaise closely between the PR team and other integrated respiratory care teams in the community and secondary care to deliver effective evidenced based care, using resources efficiently to achieve the best possible outcomes in keeping with the National Clinical Programmes-Respiratory guidance documents.
This will be supported by regular rotation of the post across these services.
Informal Enquiries:
Ms. Carmel O'Connor, Assistant Director of Public Health Nursing
Tel: 0872939051
Email: ******