Abstract
Summary: This workshop is structured around the five levels of care provided for in the National Framework for the Integrated Prevention and Management of Chronic Disease in Ireland. We will provide real world examples and share our experiences of implementing and delivering new integrated care services at scale in Ireland. The framework takes a generic, multi-morbidity approach to the prevention and management of four major chronic diseases: type 2 diabetes; asthma; COPD; cardiovascular disease. In 2021, our achievements in delivering national change in primary care (level 1 of our framework) were internationally recognised by the United Nations Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases Award(1). In tandem with our successes however we also acknowledge our set-backs and roadblocks - and seek to share our insights on our continuing journey to full implementation.
Background: The National Framework for the Integrated Prevention and Management of CD in Ireland describes five levels of service provision to deliver integrated end-to-end care for CD: Level 0:Community supports; Level 1: Primary Care; Level 2:Community Specialist Teams; Level 3:Acute specialist ambulatory care; Level 4:Specialist hospital care.
Aim: The aim is to provide real-world examples and share our experiences on our path to implementing integrated care services for CD at scale in Ireland.
Objectives:
1.Share our framework: how we have sought to transform the patient journey across CD in Ireland
2.Share our successes: Structured illness and preventive care in general practice
a.UN Inter-Agency Task Force on the Prevention and Control of Non-communicable Diseases Award recipient.
b.How the GP programme pivoted to protect the most vulnerable cohort during the first wave of COVID-19.
3.Share our challenges: how to attract, train and retain staff?
Target audience: We anticipate that this workshop will appeal to a broad international audience and range of integrated care professionals (from primary care, community care to acute care, public health physicians, commissioners and health service managers) – as well as to patients themselves. It may be particularly relevant to those working in CD.
Format:
A.Overview of the model: [OOR] -5minutes
B.Presentations [7minutes & 5minutes discussion]
I.Level 0 - Making Every Contact Count [MOB]
II.Level 1 - A new GP contract in action [OOR]
III.Level 2 & 3 - Increasing Primary Care access to Diagnostics & Specialist Opinion in the Community [SOB]
IV.Level 4- Integrated Care Consultants – recruiting to a new speciality? [KMcD]
V.Example in Practice: seeking the patient perspective on the end-to-end pathway for DM care [LH]
C.Interactive discussion:[10mins small groups; 10min questions to panel]
Implementation at Scale – Lessons Learned
D.Sum-up and closing remarks - 5 mins [OOR,SOB]
Key Learnings/Take away: We are transforming CD care in Ireland. Our generic integrated care framework targets each level of care for CD from community-based supports to the acute hospital. Sustained action, despite challenges, over the past decade has resulted in unprecedented funding and rollout of this seminal and internationally recognised programme
Reference:
1. 2021 United Nations Inter Taskforce Awards. https://www.who.int/news-room/events/detail/2021/09/22/default-calendar/2021-united-nations-interagency-taskforce-awards