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

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

3. 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

5. How can “the system” help us?

6. Models of care

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

8. 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.

9. Understanding Frailty

11. 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

12. 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 % % % %
23.7%
Adapted from Roe et al., TILDA 2016. 17

13. 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.

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

15. 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.

16. 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.

17. 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

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

20. 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 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 posts
CHO 9 – Connolly
CHO 9 – MMUH
9 CHOs and 14 Hospitals by end of 2018
25 days
PJH, Dr SK (ICP OP)

21. 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) .

22. Community Health Network

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

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

26. 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