Enhanced Community Care for Chronic Disease: working together to deliver person-centred care closer to home

Abstract

Seven chronic disease modernised care pathways (MCPs) were funded for national implementation in Ireland in 2023. The MCPs set out how scheduled care may be delivered closer to home, in a more effective and efficient manner, shaped to meet the clinical need of the individual referred. Against the backdrop of varying levels of progress in implementing the MCPs across Ireland, and increased demand for scheduled care services, a joint initiative between the Integrated Care Programme for the Prevention and Management of Chronic Disease (ICPCD) and two regional integrated care teams was developed with the aim of enhancing integrated working across the acute and community cardiology services. Local Cardiology Integrated Care Working Groups were established at each site comprising frontline clinicians and senior decision makers from acute hospital and aligned community specialist teams. A National Scheduled Care Working Group was established to provide strategic guidance and support the local teams to implement locally agreed solutions. The local groups agreed a shared vision and consulted with GPs and service users to map out the patient journey to identify priorities for action. Solutions were developed using PDSA cycles at each site, with progress reviewed and processes refined at the weekly meetings. This initiative demonstrated the positive impact of the full implementation of the MCPs on delivering a more timely, responsive scheduled care service. Over 30% of GP referrals to the hospital outpatient service can be dealt with by the community specialist teams. Over 50% of referrals into community specialist teams can be managed through virtual means. Service users value the more responsive approach to care through virtual and in-person offerings. The establishment of the local working groups involving senior decision-makers across acute and community was an important enabler in building relationships and networks to drive change and the delivery of an integrated, person-centred scheduled care service. Collective changes in practice across acute and community team members enabled delivery of a more efficient, effective and responsive service with reduced waiting times achieved across both sites. This initiative has highlighted the benefits of harnessing technology and the delivery of the MCPs by the community specialist teams to reduce waiting times for scheduled care. More importantly, it has demonstrated the benefits of improved collaboration across acute and community at the local level to shape the scheduled care services to better meet patient need. Systems leadership where all team members collaborated across healthcare environments and disciplines to achieve common goals enabled a focus on delivering a person-centred service, as opposed to a focus on delivering a service within traditional boundaries . The pooling of resources, data and expertise, underpinned by PDSA cycles and co-design of solutions delivered a more agile and responsive service. The national role was one of enablement and this has been identified as an important factor in supporting a culture of integrated working within the health and social care services