* Ireland
* Full time, Permanent
Who We Are
HSE Dublin & South East was established as part of the Sláintecare program, combining South East Community Healthcare, Community Healthcare East and the Ireland East Hospital Group with three hospitals from the South/South West Hospital Group: University Hospital Waterford, Tipperary University Hospital, and Kilcreene Orthopaedic Hospital. The new regional health region confidently takes on the responsibility of providing acute and community healthcare services across the country.
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Description
Details of service
A significant programme of reform is underway in Services for Chronic Disease Management and Services for Older People, supported by the strategic direction set out under Sláintecare, the Enhanced Community Care business case, the HSE Corporate Plan, the National Service Plan and the National Clinical Programmes. This Enhanced Community Care Programme is currently transforming the way healthcare is being delivered nationally, shifting the focus away from acute hospitals towards a new model of specialist integrated care in the community, bringing together hospitals, community services, primary care, health & wellbeing and voluntary sectors to develop new networks of care for older people and people with Chronic Disease.
The investment in an Enhanced Community Care (ECC) Model will be delivered on a phased basis with a view to national coverage being achieved within a 2 to 3-year period. Three priority areas have been identified as follows:
1. Structural reform with Community Health Networks (CHNs) becoming the basic building blocks for the organisation, management and delivery of community services across the country.
2. Creating Specialist Ambulatory Care Hubs as a secondary care model for the management of Chronic Disease and Older People with complex needs.
3. Scaling Integrated Care for Older People and Chronic Disease through the recruitment of specialist integrated care teams including Frailty at the Front Door Teams.
The focus is on an end-to-end pathway, including Specialist Care Community Hubs that will prevent admissions to acute hospitals where it is safe and appropriate to do so. For patients who require admission, the emphasis is on minimising hospital stays and improving outcomes, with post discharge support for people in the community and in their own homes. A shared local governance structure across Acute hospital and CHO ensures the development of a fully integrated service and end-to-end pathway.
The ECC Model is underpinned by a set of key principles including:
* Eightypercent of services delivered in Primary Care are through the GP and Community Healthcare Networks (CHN’s).
* Identifying and building health needs assessments at a Community Healthcare Network level (approximate population of 50,000) through a population stratification approach to include identification of people with chronic disease and frequent service users, thereby ensuring the right people get the right service based on the complexity of their health care needs.
* Utilisation of a whole system approach to integrating care based on person centred models, while promoting self‑care in the community.
* The Chronic Disease/Older Persons Service Model sets out the end to end service architecture for the identification and management of people living with chronic disease and frail older adults with complex care needs.
* Learning from and delivering services based on best practice models in the Community Healthcare Networks and the extensive work of the integrated care clinical programmes particularly in Chronic Disease and Older Persons services.
* Embed preventative approach to healthcare into all services.
* Availability of a timely response to early presentations of identified conditions and the ability to manage appropriate levels of complexity related to same.
* Resources applied intensively in a targeted manner to a defined population, implementing best practice models of care to demonstrate the delivery of specific outcomes and sustainable services.
* The need to frontload investment, coupled with reform to strengthen community services.
In line with Sláintecare (2017) and the Department of Health’s Capacity review (2018), a shift in healthcare service provision is now required to place the focus on integrated, person‑centred care, based as close to home as possible. In order to enable this, the Integrated Care Programme for the Prevention and Management of Chronic Disease (ICPCD) is supporting a model of integrated care that has a particular focus on preventive healthcare, early intervention and supports to live well with chronic disease. The implementation of integrated care is dependent on the development of community‑based, multidisciplinary roles.
The aim of the Chronic Disease Community Specialist Team is to support evidence‑based GP‑led care for individuals with specific chronic disease in the community with a particular focus on patients enrolled on the GP Chronic Disease Management Programme which commenced with the Treatment Programme in 2020. The new Chronic Disease Management Programme focuses on the four major chronic diseases: Cardiovascular Disease (CVD), Chronic Obstructive Pulmonary Disorder (COPD), Asthma and type 2 Diabetes Mellitus (DM). The Chronic Disease Specialist Team will be made up of a range of medical staff, Health and Social Care Professionals (HSCPs) and Clinical Nurse Specialists with expertise in managing one or more of the four major Chronic Diseases. This team will be based in the Specialist Ambulatory Care Hub.
Specialist Ambulatory Care Hubs will serve a population of approximately 150,000 and serve three Community Health Networks and are affiliated with a local hospital. Each Hub will be located outside of the hospital in the community. Each Hub will focus primarily on the prevention and management of complex chronic disease and will provide access to specialist services within the CHN. These Hubs will be established to support the provision of care closer to home and to facilitate ready access to diagnostics, specialist services and specialist opinions in order to enhance the delivery of patient‑centred care, support early intervention and avoid hospital admission where possible.
Providing support from multidisciplinary Chronic Disease Specialist Teams, access to diagnostics (including radiology and laboratory testing) and the development of a suite of pathways as alternative options to outpatients will support the work within each Hub and the provision of the right care, in the right place, at the right time.
The Integrated Chronic Disease Service will support:
* A holistic, multidisciplinary approach to the care of patients with Chronic Disease
* Early intervention pathways/rapid access clinics for acute, chronic or newly‑presenting conditions
* Development of pathways for the management of chronic conditions. The early assessment and implementation of pathways that will support GP‑led primary care, efficient discharge back to the community where appropriate, and reduce the need for repeated hospital‑based outpatient reviews
* Provision of oversight and implementation of self‑management support services in the ambulatory care hubs
* Increased access to specialist review and referrals for diagnostics by the GPs
* Provision of a reformed outpatient services that utilise tele‑health and other ICT measures to facilitate more effective and efficient delivery of care
* Reduced waiting times for patients for hospital outpatient services
* Timely access to specialist services and specialist opinion for patients with chronic disease and associated co‑morbidities.
Background to the Post:
As outlined above, the need to reform the healthcare services in Ireland in order to provide a more sustainable, integrated and patient‑centred approach has come to the fore in recent health policies and strategies. The post must be congruent with the requirement of Sláintecare, HSE National framework for the Prevention and Management of Chronic Disease and the Enhanced Community Care Business Case.
Integrated care requires health and social care services to work together across different levels and sites in order to provide end‑to‑end care that meets patient need. As described in the Sláintecare report (2017), integrated care involves:
1. Ensuring appropriate care pathways are developed with a focus on person‑centred service planning to ensure services are built around patients;
2. Supporting timely access to all health and social care services according to medical need;
3. Patients accessing care at the most appropriate, cost effective service level with a strong emphasis on prevention and public health.
The Operational Team Lead Integrated Care ICPCD Specialist Community Team role is multifaceted:
* The post holder is responsible for the operational management of the Chronic Disease Hub. The post holder will operationally manage all of the staff in the Hub. Professional reporting for all disciplines will continue with the relevant HOD/DPHN or other as appropriate.
* The post holder will ensure that team structures are attended to so that the service is consistent with recognised best practice in team functioning.
* The post holder will have oversight of activity within the Chronic Disease Community Specialist Teams and will have responsibility for developing and implementing care pathways in collaboration with Chronic Disease Specialist Teams in the acute and community settings.
* The post holder will play a pivotal role in collaborating with the Community Healthcare Network Manager and the ICPOP Team Co‑ordinator to adopt a population based approach to services, completing a population stratification and identifying those clients most at risk, for management within the CHN and Specialist Teams.
* Work across the services to develop integrated improvement plans for planning care and patient flow thereby ensuring an effective partnership of care between patients, families, carers and healthcare providers in achieving safe, easily accessible, timely and high quality care.
* The post holder will co‑ordinate a model of active referral management in conjunction with GP’s and Community Healthcare Networks and relevant Discipline managers within the Chronic Disease Specialist Teams to support patients to access the appropriate care pathway they need in a timely manner.
* The post holder will work with the Consultant Leads/Project MDT and existing outreach/ in reach services to develop integrated criteria for referral and on‑going support ensuring a seamless continuum of care for the patient.
* The post holder will ensure that all services are operating optimally within the specialist teams and in collaboration with relevant discipline managers provide oversight of waiting lists and access to services within the Chronic Disease Specialist Team.
* The post holder will ensure patients with chronic disease are facilitated to understand their care needs and to work in partnership with the Multidisciplinary Team (MDT) in the Hub and wider community e.g. peer groups supports to ensure optimisation of their care in the ambulatory model.
10. The post holder will Line manage the Project Support Officer and Administrative staff to support the operations of the Specialist Team.
Location of post
HSE Dublin & South East
There is currently 1 permanent whole‑time vacancy available in Wexford.
A panel may be formed as a result of this campaign for Operational Team Lead, Integrated Care Programme, Chronic Disease from which current and future, permanent and specified purpose vacancies of full or part‑time duration may be filled.
Tel: 087 6405872 for further information about the role.
We recommend that applicants wishing to apply should submit their application a minimum of 1 hour before the closing date and time and make sure they can see their application is submitted in their Rezoomo profile. Applications will not be accepted after this date and time, no exceptions will be made.
Paid Time-Off for Vacation and Sick Days
Dublin and South East Recruitment for Carlow/Kilkenny/Tipperary South/Waterford/Wexford Communities is an Equal Opportunity Employer
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