Enhancing clinical practice in Community Nursing

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Presentation transcript:

Enhancing clinical practice in Community Nursing Integrated care programmes Dr David Hanlon GP National Clinical Advisor Primary Care

It is all about the patient But we need to mind the professionals too

A Successful Team Needs all the players on the pitch (and a few subs) Needs the right equipment & venue Needs the right mixture of skills Needs to know each other and others roles Needs to communicate effectively & efficiently

How can “the system” help us?

Models of care

Integrated Care For Older People- Opportunities & Challenges Siobhán Kennelly & Diarmuid O’Shea ICPOP & NCPOP

Aims and Objectives of ICP OP The aim of the Integrated Care Programme for Older Persons is to develop and implement integrated services and pathways for older people with complex health and social care needs, shifting the delivery of care away from acute hospitals towards community based, planned and coordinated care.

Understanding Frailty

Frailty in Ireland Roe et al., TILDA 2016 TILDA participants aged 65 years and older (n=3,422) categorised as: - robust (0-3 health problems), - pre-frail (4-7 health problems), - frail (8 or more health problems). Roe et al., TILDA 2016

Prevalence of Frailty in Ireland Figure 1. Prevalence of frailty among community-dwelling older adults (>65) in Ireland: data from The Irish Longitudinal Study of Ageing 16.9% 28.7% 26.5% Dublin Antrim Cork Galway Prevalence of Frailty in Ireland 15-19.9% 20-24.9% 25-27.9% 28-29.9% 23.7% Adapted from Roe et al., TILDA 2016. 17

Integrated Frailty Care: Core components Person-centred care, Effective communication & Case management Regular, ongoing and pre-planned communication between senior partners in the relevant organizations is important for success in integrated care interventions.  Data sharing & common data sets can improve flow and information exchange. Case managers are useful as central coordinators linking multi-disciplinary teams to integrate services. Co-location an advantage.

Case management can: Reduce institutionalisation. Reduce hospitalisation, Improve ADL function, Reduce use of inappropriate medication, Target use of community services.

Integrated Frailty Care: Core components Multi- and inter-disciplinary services & Comprehensive Geriatric Assessment (CGA) MDTs/IDTs promote horizontal integration through common goal & value setting and through improved communication. CGA: individualised multi-domain assessment by a MDT/IDT using validated scales and interventions.

Interventions targeting Frailty 9/14 studies involving community-dwellers ≥65 found to reduce level of frailty. Effective interventions targeted: Exercise, Nutrition, Cognitive training, Geriatric assessment and management, Prehabilitation (peri-operative aerobic exercises, strength training, and functional tasks). Adherence rates around 70% for most studies.

Frailty Pathways in Practice Frailty MDT CGA ED Triage & Admission Seen by Doctor Seen by nurse Physio Assessment Rehabilitation OT and PT assessment Care at home Discharge Home Care at Home Primary Care /PHN Discharge Home Discharge Planning Rehab in hospital Formal Rehab OT Assessment Modified from Latana A. Munang, St Johns Hospital, Lothian, Scotland

ICPOP Sites and Frailty Education Integrated Care Sites NCPOP Frailty Education Programme

ICP OP Programme Development Networking Day Networking Day Networking Day ICP OP Team Recruited Frailty Education Clinical Lead/PM recruited Networking Day ICT (Hardware) PID agreed & Programme Governance established Lit Review Completed Consolidate Funding allocated €1.7m Further 6 pioneers sites under development 6 pioneers sites established Outcome measures 12 pioneer sites established Pop. Planning AFI launch IC Guidance Launch Data collection Nov 7 Aug Dec Jan Dec Jan JULY Oct Dec Dec 20 2018 Today 2016 2016 2017 2018 6 days 18 days 24 days Pioneer sites (2016) CHO 1 - Sligo CHO 4 -CUH CHO 6 – SVUH 35 posts CHO 7 - Tallaght CHO 8 - OLOL CHO 9 - Beaumont 16 days Pioneer sites 2017 CHO 3 – Limerick CHO 4 - MUH CHO 5 - Kilkenny CHO 5 – Waterford 15 posts CHO 9 – Connolly CHO 9 – MMUH 9 CHOs and 14 Hospitals by end of 2018 25 days PJH, Dr SK (ICP OP)

Change methodology critical! The attributes that lead to systemic improvement in healthcare are different. Complex systems self organise, therefore imposing a rigid design doesn’t appear to work in systemic change. Co-design and creating conditions for improvement based on shared narrative. Social movement (Bate 2004, Buchanan 2003, Ovretveit 2011, Velsman and May 2014) set within ‘hard edges’ (Dixon-Woods et al 2011) .

Community Health Network

ICT Digital IDs - NOW Devices- NOW Primary Care management system – 2019 Shared Record Community Clinical System Acute EHR

ICT Digital IDs - NOW Devices-NOW Primary Care management system - 2019 Shared Record- 2020 Community Clinical System ? Acute EHR – Children’s Hospital 2022

Take home message The future of community nursing is bright Sláintecare Capacity review Extended roles Technology Structures Models of care delivery New challenges New opportunities