Integrated Care for Chronic Disease: Practical Change management to support implementation of new ways of working and scaling of implementation.

Abstract

Background: The Enhanced Community Care programme supports the operationalising of the full end to end Integrated Care programme for the Prevention and management of chronic disease model of care in Ireland . The implementation is built on the nine pillars of Integrated care to implement community based care for chronic disease (type 2 diabetes, respiratory (asthma and COPD) and cardiology at scale across Ireland using a change management approach.   Approach: This paper outlines the approach to creation of shared values and vision through change management approach. In 2021, 30 Chronic disease community specialist teams were newly funded with dedicated specialist multidisciplinary chronic disease staff including: Integrated Care (IC) Consultants which is a new role working across hospital & community; additional nursing & Health and Social Care professionals, and a key role of Operational Lead to manage and co-ordinate the operationalising of services for through new pathways and ways of working.   Change management and clinical guidance to implement the end to end MoC through new pathways and ways of working has been supported and co-ordinated through the National central based team using the HSE Change Guide3 by Creating a shared purpose - ensure understanding of the MoC and create commitment to model. Stakeholder engagement and planning in each region to ensure stakeholders are involved in the process including patient engagement Focus on the people and the culture change –to understand the local context of each team and to move to the new ways of working.   Results:The results of this sustained support and collaboration with the 30 teams has resulted in: Teams delivering a range of services for patients with chronic disease to meet population needs. Collective approach applied to find solutions to challenges including ICT, equipment, standard operating procedures for pathways. Local Chronic disease Governance groups including leadership across community and acute services have been established Strong Clinical Leadership at National level and local level HSE regions through network of New Integrated Care Consultants (IC) groups. Sustained tailored engagement process designed and implemented all teams and stakeholders Monthly engagement with National Operational Leads network focusing on interdisciplinary ways of working and showcasing examples of good practice Monthly suite of metrics collected across teams which opportunities for improved productivity through targeted support and change management /service improvement initiatives. Patient engagement and involvement through feedback surveys in local teams is used to implement service improvements and increase patient impact of the services.   Implications:Practical change management support across the teams has changed with the evolution of the implementation of the programme, feedback from patient surveys and shared learning across teams. Continued shared learning and service improvement through examples of good practice will continue to increase the impact of services for patients with chronic disease . Focus on increased patient stories and testimonials to demonstrate the impact and benefits of the services for patients with chronic disease and to further co design services into the future.