Kerry has an ageing demographic with evidence of a high population living with frailty in the community and have long term conditions increasing their risks of clinical and/or functional decline. Tilda reports from 2020 noted that there were 16,500 individuals ages 70 or over living with frailty in Kerry (O’Halloran et al., 2020). According to the CSO, Kerry has one of the oldest populations in Ireland with an average age of 41.5 years in April 2022. The county has the highest proportion of older people with 23.1 % of the population aged 60+ and 9,910 people aged 75+. Additionally, the number of people living alone in Kerry grew significantly by 26% between 2016 and 2022 censuses.
A significant programme of reform is underway in Services for Older Persons and Chronic Disease supported by the strategic direction set out under Sláintecare (2017), the Enhanced Community Care (ECC) business case (2019), HSE Corporate Plan (2020), National Service Plan (2021) and the National Clinical Programmes.
The Enhanced Community Care Reform Programme (ECC) is focused on the transformation of community care with an emphasis on establishing Community Health Networks and Specialist Community Teams working within Ambulatory Community Hubs. These plan and organise services for a defined population, enable integrated care to be implemented, shifting the focus away from acute hospitals towards a new model of specialist care in the community. The redesign of services allows new pathways to be developed between 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 Model will be delivered on a phased basis, with a view to national coverage being achieved within a 2–3-year period.
Three priority areas have been identified as follows.
Structural reform with Community Health Networks (CHNs) becoming the basic building blocks for the organisation, management and delivery of community services across the country.
Creating specialist ambulatory care hubs within the community for the management of chronic disease and older people with complex needs.
Scaling Integrated Care for older people and chronic disease through the recruitment of specialist integrated care teams across the care pathway including Frailty at the Front Door Teams.
The ECC Model is underpinned by a set of key principles including:
Eighty percent of services delivered in Primary Care are through the Community Networks.
Identifying and building health needs assessments at a Network level (approximate population of 50,000) based population stratification approach to identify people with complex, longitudinal care needs that require integrated care. This targets older people living with frailty and people with chronic disease who are high need service users, thereby ensuring the right people benefit from care pathways that deliver care closer to home, based on the complexity of their health care needs.
Utilisation of a whole system approach to integrating care based on person centered community models, while promoting self-care in the community.
Learning from and delivering services based on best practice models in the community and the extensive work of the integrated care clinical programmes particularly in Older Persons and Chronic Disease 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.
Embed a preventative approach into all services.
The Integrated Older Persons 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. The focus is on providing an end-to-end pathway that will reduce admissions to acute hospitals by providing access to diagnostics and specialist services in the ambulatory care hubs in a timely manner. For patients who require hospital admission, the emphasis is on minimising the hospital length of stay, with the provision of post-discharge follow up and support for people in the community and in their own homes, where required. A shared local governance structure across the local acute hospitals and the associated CHO will ensure the development of a fully integrated service and end-to-end pathway.
The integrated older persons service is a specialist multidisciplinary service primarily targeting and managing the complex care needs of the older person with multiple co-morbidities across a continuum of care. The overall aims of the service are to:
Provide a specialist geriatric opinion using an interdisciplinary approach to support older people with complex care needs.
Develop a person-centred care planning approach that supports robust and timely communication across care settings.
Support appropriate and timely reduction of Emergency Department (ED) attendance through the development of care pathways that support GPs and others in assessment of older people with escalating care needs.
Provide support and education to the older person, carers and healthcare professionals.
The cANP Older Persons will work as a member of the integrated care team for older persons across services in the Assessment hub for older adults/primary care and acute settings assessing the frail older adult, identifying an appropriate care pathway and informing their plan of care. The HSE service plan and all recent strategies and policies aim to avoid hospital admission and plan care in an appropriate setting, when necessary, e.g. at home, step up/step down beds, rehabilitation beds, respite beds. The role will support the establishment of integrated care pathways for older persons.
The cANP Older Persons will work with the Consultant Geriatrician Led interdisciplinary team. The RANP role will involve the assessment of the older adult who has been referred to the sevice. This role ensures appropriate use of resources and assists with patient flow.
The overall purpose of the cANP in older person care is to provide safe, timely, evidenced based nurse led care to patients at an advanced nursing level. This involves undertaking and documenting a complete episode of patient care (assess, diagnose, plan, treat and discharge patients) according to collaboratively agreed protocols and scope of practice in the clinical setting, demonstrating advanced clinical and theoretical knowledge, critical thinking and decision-making skills.
Purpose of the post
The cANP (Older Persons) demonstrates advanced clinical and theoretical knowledge, critical thinking, clinical leadership and complex decision-making abilities.
The cANP (Older Persons) practices in accordance with the Code of Professional Conduct and Ethics for Registered Nurses and Registered Midwives (NMBI, 2014), the Scope of Nursing and Midwifery Practice Framework (NMBI, 2015), Advanced Practice (Nursing) Standards and Requirements (NMBI, 2017), and the Values for Nurses and Midwives in Ireland (Department of Health, 2016).
The cANP (Older Persons) service provides clinical leadership and professional scholarship in the delivery of optimal nursing services and informs the development of evidence-based health policy at local, regional and national levels.
The cANP (Older Persons) contributes to nursing research that shapes and advances nursing practice, education and health care policy at local, national and international levels.
The cANP (Older Persons) has a role in the ongoing development of the Integrated Care Programme for older persons in the South West region.
We Welcome Enquiries About The Role
Kathleen O DonoghueOperational Team LeadKerry Integrated Care Program for Older Personskathleen.odonoghue1@hse.ie0873580668Contact Meaghan McGlynn – Campaign Lead at meaghan.mcglynn@hse.ie for enquiries relating to the recruitment process.
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