Overview
The successful candidate will be part of the Integrated Respiratory Care team.
About the Role
In line with Slintecare (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).
About the Model of Care
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.
Priorities
* 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.
* Sscaling Integrated Care for Older People and Chronic Disease through the recruitment of specialist integrated care teams including Frailty at the Front Door Teams.
Focus Areas
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.
Key Principles
* 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.
* Embedding a 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.
Ambulatory Care Hubs
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 disease.
The Integrated Respiratory Service
The Integrated Respiratory Service will support:
* A holistic, multidisciplinary approach to the care of individuals with chronic respiratory disease.
* Provision of a reformed outpatient service that utilises telehealth and other ICT measures to facilitate more effective and efficient delivery of care.
* Reduced waiting times for patients for hospital-based outpatient services.
* Timely access to specialist services and specialist opinion for patients with respiratory disease.
* Early intervention pathways/rapid access clinics for acute, chronic or newly presenting respiratory conditions.
* Development of pathways for the management of chronic conditions.
Duties and Responsibilities
The person appointed to this post will work in the overall respiratory service with 50% of time based in the acute setting and 50% of time based in community supporting the respiratory consultants as required.
The post holder will work as part of a multidisciplinary team delivering coordinated evidence-based care for respiratory patients.
Please note a portion of the appointee's work will be carried out