The Development and Implementation of a Community-based Integrated Care Programme for Older Persons service in a Irish healthcare region (CKCH)

Background: Ireland’s aging population represents a measure of success in improving health and extending life expectancy however, while many older people remain well, engaged and active well into later life and continue to make a major contribution to local communities and society, increasing age is associated with long-term medical conditions, frailty, dementia, disability, dependence and social isolation. Over the past four years, Cork Kerry Community Healthcare (CKCH) has recognised the need for age-attuned services as outlined in the National Clinical Program for Older Persons (NCPOP). Aim: The CKCH Integrated Care Programme for Older Persons was established with the aim of deployment and testing of integrated care pathways, developing new roles and service models. More specifically, the integrated care hubs seek to improve the quality of life of older persons and their support networks by providing access to integrated care and support, specifically tailored to their needs and choices, thus supporting them to live well. Highlights: There are three ICPOP hubs currently in operation in CHO4 (Kerry ICPOP, Cork South City and Cork North). There is uniformity in terms of policies, procedures, protocols, guidelines and clinical guidelines across all hubs. A number of pathways provided within each hub demonstrate a new ecosystem of care and reflect the transformational nature of change the health system is undergoing: A.An Ambulatory care hub for Older Persons supporting primary care, Community Health Networks (CHNs) and hospital attendance/ admission avoidance. B.Early Supported Discharge/Outreach providing rehabilitation in clients’ own home environment C.Nursing Home Support Service which delivers equity access of care to all clients and reduces unnecessary conveyance to acute hospitals D.GEMS/Frailty Front door follow up supporting acute hospital capacity issues through a discharge to assess model. E.CHN interaction thus embedding integrative practices into primary care F.Education & Research aimed at the development of an age attuned workforce and the development of services that are meeting the populations needs Whilst difficulties continually exist in the implementation of the national vision, significant progress has been made, in overcoming these obstacles through a cohesion of efforts at CKCH CHO 4 level. Implications for clinical practice: Plans for CHO4 ICPOP services include the progression of robust governance structures, the development of acute hospital in-reach, and progression of two further hubs in Cork. Consideration is also to be given to the development of regional clinics for syncope, movement disorders and Memory Assessment and Support Services, the development of satellite clinics/residential care facility supports in areas such as West Cork/Kerry, the further development of Early Supported Discharge/Outreach teams into CHNs . Embedding of a research model and improved service user involvement to improved patient services also requires progressing. Conclusions: Key learnings from scale up emphasise the critical importance of effective communication nationally/locally in operationalising a vision. Local relationships are invaluable. Unfortunately, effectiveness of the services may take time to manifest and there is a risk that effects are offset by changes to patient demographics. Clear governance pathways require ongoing development and are key to ongoing success