Dáil Éireann Debate, Thursday - 6 July 2023
340. Deputy Fergus O'Dowd asked the Minister for Health to provide on update on the Programme for Government commitment on the target of community services assigning a case manager for older people with chronic conditions to assist them with accessing the care they need, since the establishment of the current Government; and if he will make a statement on the matter. [33313/23]
View answerIreland’s population is ageing rapidly, and for the most part, our older population clearly indicates their preference to age in place, in their own homes, for as long as possible. One of the Government's key priorities, as outlined in the Programme for Government, is to support older people to live in dignity and independence in their own homes and communities for as long as possible. This is in line with the Sláintecare vision for receiving the right care, in the right place, and the right time.
The Government remains committed to supporting older people to age in place at home, in their communities, with access to wraparound supports, including day care and dementia-specific day care services, Meals on Wheels, and home care services.
In 2021, the HSE commenced the implementation of the Enhanced Community Care (ECC) Programme, which aims to deliver increased levels of healthcare, with service delivery reoriented towards general practice, primary care, and community-based services.
The ECC programme will ensure maximum impact for citizens in avoiding hospital admission as far as possible through initiatives that will see care delivered within the community, at or near a person’s home, where appropriate.
ECC funding will support the ambitious, programmatic, and integrated approach to the development of the primary and community care sector which, amongst other initiatives, includes the development of primary care teams within 96 Community Healthcare Networks across the country, alongside 30 Community Specialist Teams for Older People, 30 Community Specialist Teams for Chronic Disease, and national coverage for Community Intervention Teams.
As part of the ECC programme, the Integrated Care Programme for Older Persons (ICPOP) aims to shift the delivery of care away from acute hospitals towards a community based, planned and co-ordinated care model which is closely aligned to Primary Care and Acute sector partners.
The objective of the programme is to improve the quality of life for older people by providing access to integrated care and support that is planned around their needs and choices. The programme seeks to ensure that older people with complex care needs can access care quickly, at or near home, through care pathways specifically designed for older people and targeting Frailty, Falls and Dementia. ICPOP has worked with acute hospitals and their local community older person’s services to develop end-to end care pathways for older people with complex care needs.
Each Community Specialist Team will service a population on average of 150,000 across an average of 3 Community Healthcare Networks (CHNs). The teams will be co-located together in ‘hubs’ located in or adjacent to Primary Care Centres, reflecting the shift in focus away from acute hospitals towards general practice, primary care, and a community-based service model.
As of April 2023, 23 ICPOP teams have been established across the country. It is envisaged that the full complement of 30 ICPOP teams will be established by Q4 2023.
In line with HSE national guidance, each Community Specialist Team (CST) provides for case management. Case Management is a complex function that involves organising and coordinating care. It forms a cornerstone of a new way of working that proactively identifies and delivers secondary care in the community for older adults with complex needs and long-term conditions such as frailty. Whilst case management has a broad function, care coordination at a minimum involves proactively supporting patients to access services, avoid duplication, and optimises outcomes.
A case management function involves collaborative and multi-disciplinary approaches to organising and coordinating care for the individual. It typically comprises of a case finding, needs assessment, care planning, care coordination and case closure. Each member of the CST Older People team, irrespective of discipline, undertakes a care co-ordination function. The case management function with CSTs for Older People is based on Comprehensive Assessment. As well as undertaking comprehensive assessment, CSTs team members will case manage care until outcomes are optimised.
This will include teams agreeing with other care provides (primary and secondary care) how meeting care needs are shared. The needs of people with complex care needs requires proactive care co-ordination, with Multi-Disciplinary Team members sharing that function (referred to as assertive case management). The clinical management of people attending the service is focused on being person-centred and may include enhanced management/interventions in people’s own homes or in other community settings.
