In line with Sláintecare priorities, the Enhanced Community Care Programme (ECC) objective is to deliver increased levels of health care with service delivery reoriented towards general practice, primary care, and community-based services. The focus is on implementing end-to-end care pathways that will care for people at home and over time prevent referrals and admissions to acute hospitals where it is safe and appropriate to do so.
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.
To date, 96 Community Health Networks have been established, 24 Community Specialist Teams for older people, and 24 Community Specialist Teams for chronic disease.
Further ECC teams will be implemented in early 2024, with the focus for the Programme this year being on consolidating the progress made to date, increasing productivity and outputs to maximise impact from the existing level of resources.
Community Healthcare Networks
Through the implementation of the ECC Programme, 96 Community Healthcare Networks (CHNs) have been established, with each serving a population of on average 50,000. Each CHN is comprised of a multi-disciplinary team and provides the foundation and organisation structure through which integrated care is delivered locally at the appropriate level of complexity. This new approach will improve integrated team working between GPs, Health and Social Care Professionals, and nursing and other staff working in primary care services, moving towards more integrated end-to-end care pathways for individuals, especially older persons and those with complex and chronic conditions. Multidisciplinary Clinical Team Meetings now take place on a scheduled basis to support this approach.
Community Specialist Teams (Hubs)
The work that has been undertaken by the Integrated Care Programme for Older People (ICPOP) and Chronic Disease over recent years has shown that improved outcomes can be achieved particularly for older people who are frail, and those with chronic disease, through a model of care that allows the specialist multidisciplinary team engage and interact with services at CHN level, in their diagnosis and on-going care.
With the support of the Department of Health and Sláintecare, these models are now being implemented at scale by the HSE, with the establishment and full rollout of Community Specialist Teams for Older People and Community Specialist Teams for Chronic Disease to support CHNs and GPs to respond to the specialist needs of these cohorts of the population, bridging and linking the care pathways between acute and community services with a view to improving access to and egress from acute hospital services.
These Community Specialist Teams will service a population on average of 150,000, equating on average to 3 CHNs. Ideally, the teams will be co-located together in ‘hubs’ located in or adjacent to Primary Care Centres, reflecting a shift in focus away from the acute hospital towards general practice, and a primary care and community-based service model.
With regard to case managers for older people with chronic conditions to assist them with accessing the care they need, the HSE recognises the importance of embedding the multi-disciplinary Clinical Team Meetings as previously referenced. To ensure that these meetings are optimised and deliver a coordinated approach to individual clients, the roles of Clinical Coordinator and Key Workers have been created within the CHNs.
The Clinical Coordinator is a member of the multidisciplinary team, at senior therapy or nursing grade, and is central to the organisation and coordination of Clinical Team Meetings. A Key Worker may be identified for service users with complex needs and is also a member of the multidisciplinary team. The role of Key Worker is to assist in coordinating the delivery of services to the individual, while acting as a single point of contact and enhancing the experiences and outcomes for individuals.
The importance of the Clinical Coordinator and Key Worker roles are recognised within the ECC resource allocation, and a total of 3 WTE resources have been allocated to each CHN to allow protected time to carry out these essential functions.
Older adults with complex care needs who require the input of the Community Specialist Teams for Older People also require a proactive care coordination approach for their episodes of specialist care. As well as undertaking comprehensive assessment, MDT members will act as key workers until outcomes are optimised. This includes working collaboratively with other care providers across primary and secondary care to agree on how the older person’s care needs are to be met, in line with their will and preference, and ensuring seamless transitions back to the CHN team at the completion of the episode of specialist input.