Please Note:
All correspondence via Rezoomo No CV's accepted. Informal Enquiries Name: Alison Murphy, DSW ICPOP CST Operational Lead
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Details of Service The Older Persons Service Model sets out the end-to-end service model for the identification and management of frail older adults with complex care needs.
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 ambulatory care hubs in a timely manner.
For patients 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 integrated healthcare area will ensure the development of a fully integrated service and end-to-end pathway.
The Dublin South West (DSW) Integrated Care Programme for Older Persons (ICPOP) Community Specialist Team (CST) is a specialist transdisciplinary[1] service primarily targeting and managing the complex care needs of the older person with multiple co-morbidities across a continuum of care.
The overall aims of the service are to:
Provide a specialist geriatric opinion using a multidisciplinary approach to support older people with complex care needs. Develop a person-centred care planning approach that supports robust and timely communication across care settings. Support appropriate and timely reduction of Emergency Department (ED) attendance through the development of care pathways that support GPs and others in assessment of older people with escalating care needs. Provide support and education to the older person, carers and healthcare professionals. Clinicians in the DSW ICPOP CST, will work closely with the Consultant Geriatrician(s) and ICPOP operational team lead to develop and implement appropriate care pathways while working with primary care, community care and acute care services.
DSW ICPOP CSTs utilise a case management approach to assess and meet the complex care needs of frail older persons:
All clinicians on the DSW ICPOP CSTs are responsible for case management. This includes the completion of a comprehensive geriatric assessment with each patient in their own home. The case manager works closely with H.S.E.
primary care & community services such as PHN, HSCP colleagues, respite, home support services, nursing home support office, day care services and psychiatry of later life. The case manager has extensive links with our community and voluntary partners such as South Dublin County Council, SAGE Advocacy, ALONE, Carers Ireland, Alzheimer's Society of Ireland, Gardaí. The DSW ICPOP CSTs liaise and work closely with our acute hospital colleagues including the frailty at the front door teams, geriatric day unit (Charlie O'Toole Unit), inpatient gerontology staff.
The DSW ICPOP CSTs are based out of our new Integrated Care Hub in Clondalkin Primary Care Centre, where we are co-located with the Integrated Care Programme for Chronic Disease CST, where we have clinical space and gyms.
We have office space in Russell Centre, Tallaght Cross.
Key working relationships ICPOP colleagues include:
ICPOP Operational Lead, Consultant Geriatrician, Registrar, Advanced Nurse Practitioner, CNMII, Senior Physiotherapist, Senior Occupational Therapist, Social Worker, Speech and Language Therapist, Dietitian, Physiotherapy Assistant, Occupational Therapy Assistant, Administration colleagues. HSE colleagues include:
H.S.E.
primary care and community services such as the primary care team, (PHN & HSCP colleagues), respite, home support services, nursing home support office and day care services. Community Mental Health Nursing Psychiatry of Later Life Tallaght University Hospital colleagues:
Frailty at the front door team (GEDI - Geriatric ED Intervention) Charlie O'Toole Day Unit (TUH ambulatory hub including both Nursing and HSCP staff) Gerontology Advanced Nurse Practitioners Clinical Nurse Specialist Nursing Home Outreach Regional Specialist Memory Service Falls Service Community and voluntary partners:
Gardaí, South Dublin County Council, SAGE Advocacy, ALONE, Family Carers Ireland, Alzheimer Society of Ireland, South Dublin Partnership, Meals on Wheels.
Tallaght ICPOP Falls Prevention Advice video Follow us on X @TallaghtICPOP