Implementing integrated care in Kerry - becoming "The HSE" for our patients

The aim of our project is to develop seamless systems and processes that facilitate Kerry Community Healthcare Networks, Kerry ICPOP and University Hospital Kerry becoming “The HSE” in the eyes and experience of members of our population who require our services. Our project adapts an immediate focus on pillar two “population health and local context” by targeting the population of Kerry who require access to University Hospital Kerry, ICPOP and Community Healthcare Network services. As a result of the current political climate we are targeting our project towards individuals who are over 75 years of age and who are currently patients in University Hospital Kerry. Our aim is to develop community and acute care pathways that aim to reduce length of hospital stay and readmission to UHK while also ensuring timely transition and integration of community services to enhance patient experience. Our project team was derived as a result of analysing a patient case study within an academic assignment submission. During this evaluation it became evident that the care received by the individual was disjointed and directly resulted in poorer health outcomes for the individual. As a result of the case study evaluation it was identified that the individual required an extended stay within an acute hospital to allow for community services to be established to support transition home. At present our project team includes the following members: Community Healthcare Network Managers Assistant Director of Nursing (ADON) in Kerry ICPOP Bed Flow Manager University Hospital Kerry Our project sponsors include: Michael Moriarty, Primary Care General Manager Cork and Kerry Mary Fitzgerald, General Manager University Hospital Kerry We have developed processes locally that focus on the integration of care from acute to community services. The steps that have been implemented to create this integration include: •Sharing of complex case information at point of admission between community services and bed flow department in UHK •Attendance of Community Clinical Co-Ordinator at ward rounds in UHK on two days per week. The aim is to identify potential patients for discharge that require timely input from community services. This project is currently in pilot phase; however, the some of the anecdotal impacts are as follows: •Enhanced communication occurring between acute and community services with respect to complex patients. This results in a higher standard of care being received by the patient during their acute admission and results in greater efficiencies for staff as information is available to them. •Reduced length of stay for some patients due to community services being available immediately upon discharge; this subsequently reduces risk of readmission in first 2 weeks of discharge. The next steps for this project are as follows: •Integration of this pathway with other areas of UHK e.g. Accident and Emergency Department •Expansion of this pathway for all members of the population who reside in Kerry