Right Care, Right Place, Right Time - Enhanced Community Care

On 24th June 2021, Sláintecare hosted the 11th Right Care, Right Place, Right Time, Webinar – ‘Enhanced Community Care’

A key aspect of the Health Service Capacity Review (2018) is the shift of care out of acute hospitals into the community and closer to a person’s home, where safely possible. Enhanced Community Care is ensuring maximum impact for citizens in avoiding hospital admission as far as possible through initiatives that see care delivered within the community, at or near a person’s home where appropriate.

This webinar opened with an Enhanced Community Care Panel discussion with Dr Orlaith O Reilly, National Clinical Advisor and Programme Group Lead for Chronic Disease, Pat Healy, National Director, HSE Community Strategy & Planning and Rachel Kenna, Chief Nursing Office, Dept of Health.

Four Sláintecare funded projects which are being mainstreamed through Enhanced Community Care presented. Three are Chronic Disease Management projects, covering COPD, Diabetes, Heart Failure and one ICPOP project:

Accelerating Integrated Care for Older Persons

The main goal of the project is to provide comprehensive geriatric assessment and care for Older People in Galway in a community setting, implementing the ICPOP 10 step Framework. This will be achieved through the establishment of longitudinal integrated care pathways between the hub and the community with a particular focus on developing Falls, Frailty and Memory pathways. Through these new pathways, GPs and PHNs will be provided with an alternative to acute hospital/emergency department referral for where rapid access to specialist geriatric services (falls/syncope and memory with specialist HSCP support) is available. This will improve community access to specialist geriatric services including diagnostics and multidisciplinary assessment as well as rehabilitation and care planning leading to hospital avoidance. The project will also promote and enhance hospital discharge with follow up in Older Persons Hub, cutting down waiting times significantly.

Donegal Heart Failure Integrated Care Service

This project will enable the establishment of a Heart failure Integrated Care Service in Co Donegal to provide structured care and management for individuals living with heart failure. The availability of Heart Failure Integrated care clinics in the community setting will enable early diagnosis and treatment and ultimately improve health outcomes for people with heart failure. This will be achieved through Specialist Nurse led clinics, early access to Cardiac Diagnostic Services in Primary Care and Consultant and GP led management between Primary and Secondary Care. Increased access to heart failure services will ensure a reduction in length of hospital stay for patients and reduce the need for multiple hospital visits.

End to End Respiratory Model at 2 Sites

The Integrated Care team will deliver flexible, coordinated services for COPD patients in the community, reducing demand on hospital services. Improved access to diagnostic facilities in the community will allow for the timely, accurate diagnosis of respiratory conditions and earlier instigation of appropriate management plans. This project will formalise and strengthen relationships within a local team and provide a governance structure and ways of working that would be easy to replicate across CHNs nationwide.

End to End implementation of the Model of Integrated Care for Type 2 diabetes within 2 CHOs

This project will deliver end to end implementation of integrated Care for Type 2 diabetes in the Tuam, Athenry, Abbeyknockmoy, Loughrea Community Health Network (in CHO 2) and the Blarney and North Cork City Network (in CHO 4). All GP practices within these networks will be able to access these specialist integrated diabetes care services, which traditionally would have only been available in a hospital setting.

This webinar was the eleventh in a series of webinars and is being hosted by Sláintecare in partnership with HSE and IFIC Ireland.