Áine Lynch, Director of Nursing & Integrated Care, Tallaght University Hospital, Dublin and Gillian O’Loughlin, Operational Lead Chronic Disease Management Hub, Dublin South West, provided Conference with an insight into their lived experience of implementing the integrated care programme for chronic disease across the Tallaght, Dublin South West community catchment area linked to Tallaght University Hospital (TUH).
They discussed the challenges and enablers and shared what worked well for them.
Gillian updated the audience on the Chronic Disease Management (CDM) Hub which was part of a broader national strategy, Sláintecare, to manage the growing prevalence of chronic diseases, especially as the population aged. The hub model was designed to integrate services, ensuring that individuals with chronic conditions had access to continuous care within their communities, reducing the need for hospital visits and preventing exacerbations of chronic conditions that could lead to hospitalisations.
The goal was to create a seamless pathway for patients, where they could access multidisciplinary teams of healthcare professionals who collaborated on personalised care plans and provided self-management education programmes to help people manage their conditions safely at home, delivering the right care in the right place at the right time. Gillian reminded the audience that chronic disease management interventions required time and commitment before positive outcomes were realised.
Since 2021, there had been two hubs linked to TUH, one based in the Russell centre nearby and one in Boot Road, Clondalkin. Recruitment had been a challenge, but despite vacant posts, the hubs were delivering most of the CDM services and demonstrated positive outcomes for people in their community.
Áine and Gillian outlined that another key element of the Enhanced Community Care was the multidisciplinary integrated care programme for older persons (ICPOP). This was an enhanced community care service for older persons and was co-located with the CDM team hubs. Their work had been recognised through numerous awards including their collaboration with the Gardaí, providing training on dementia to newly qualified Gardaí in Tallaght and Rathfarnham.
How the hub team prevents hospital admission
One example: As part of the GP contract, GPs actively case- found patients who might have raised blood glucose levels and identified and referred those with pre diabetes to the Hub. The Diabetes Prevention programme was a year-long programme delivered by dietitians, providing education on diet and lifestyle to help prevent the development of diabetes. A recent review of those who completed the programme showed that 96% of participants avoided developing Type 2 Diabetes. The Diabetes team also ran a multidisciplinary team clinic, where the patients living with Type 2 Diabetes could be seen by the Consultant, Dietitian, Nurse and Podiatrist, all on the one day avoiding multiple appointments across multiple locations, improving continuity of care and providing a more efficient service for the patient.
How the hub helps to support early discharge from hospital
For example, the Respiratory integrated care team helped to reduce pressure on the hospital system by following up patients who had an exacerbation of chronic obstructive pulmonary disease or asthma who attended ED in TUH out of hours. They assessed the patient and provided support in the form of education on using inhalers correctly and managing their condition and onward referral to community services including ExWell and exercise programme, Pulmonary Rehab eight week programme, the Best health weight management programme in the hub, Quit smoking programme and many other community health and wellbeing supports which were available via the Sláintecare Healthy Communities project, another essential building block in community empowerment and wellbeing.
What has helped integrate across hospital and community services?
Governance structures included the Enhanced Community Care programme steering group and the Tallaght Hub Steering Group which enabled engagement between senior healthcare leaders from both the community and hospital together to progress implementation of integrated care between CHO 7 and TUH. Collaboration was enhanced through shared learning events, joint initiatives and projects such as leadership programmes with acute and community colleagues working on shared projects.
Other opportunities for integration included GP practice nurse study days and GP leads co-ordinating GP engagement days bringing consultants and their teams together with local GPs to highlight new services in the community and to encourage referral to hub specialist teams rather than directly to ED. To spread the word to all stakeholders and potential new staff, videos and podcasts with both clinicians’ and patients’ experience were developed and put out on social media. Support from the national clinical programmes through webinars and framework documents helped to guide services, in order to keep fidelity to the programme model.
Challenges & Opportunities
Establishing the integrated care hub was not without its challenges due to lack of access to integrated ICT systems, access to diagnostics, support with estates and clinical engineering, ‘it was like flying a ‘plane while still building it’ Gillian recalled due to recruitment taking place over the first two years.“ As staff were on board we would open up a new pathway on HealthLink, so that GPs could refer into the hub”. Work arounds were found by building on what had been learnt from existing Sláintecare projects already established in the community.
While there were challenges, the new service provided a number of opportunities, for example new technologies and the provision of rotational undergraduate student placements across the hospital and community.
Áine and Gillian said they both believed that there were significant opportunities in the integrated care space for research, innovation, partnering with industry and academia. Integrated care needed to be reflected throughout contemporary curricula for healthcare professionals. A co-design approach with patients and service users was necessary to shape new pathways of care.
The presenters acknowledged the value of good relationships and the importance of mutual respect. Their tip to the audience was to refer to the Health Service Change Guide which provided a model of change for successful integration investment in teams, collective leadership, working towards a shared goa and, engaging and communicating with staff and service users to ensure appropriate pathways of care and a holistic approach to healthcare were delivered in the right place at the right time.
