Making interdisciplinary working a reality: The Integrated Care Programme for the Prevention and Management of Chronic Disease in Ireland

The implementation of the Integrated Model of Care for the Prevention & Management of Chronic Disease (MoC) in Ireland aims to deliver patient centred care and is being implemented at scale.  This workshop aims to present examples of implementation of this change in Ireland and how we are supporting the implementation of the MoC and ensuring fidelity.  We will also demonstrate specific local examples of interdisciplinary working.

Background: An interdisciplinary approach involves team members from different disciplines working collaboratively, with a common purpose to set goals, make decisions, share resources and responsibilities.  Interdisciplinary working is being supported using a service improvement and change management approach through our MoC, design of metrics, governance structures and communication and stakeholder engagements.  The MoC takes a generic, multi-morbidity approach to the prevention and management of four major chronic diseases: type 2 diabetes; asthma; COPD; cardiovascular disease.

Aims and Objectives: To describe and showcase some successful local examples of our real-world experience of implementing good interdisciplinary working to implement a MoC placing an emphasis on the delivery of a person-centred service to improve population health.

Objectives:

1.Provide an overview of the MoC and progress to date

2.To describe how we are supporting and enabling interdisciplinary working through service improvement and change management approaches

3.To demonstrate local examples of interdisciplinary working

4.To outline initial evaluation outcomes and impact including PROMS.

5.To discuss the future of integrated care in Ireland: building on successes & learning from challenges

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.

 

Format:

A.Presentations

a.Overview of the Integrated MoC (5 mins)

b.Supporting interdisciplinary working  through service improvement  (5 mins)

1. Change management approaches (5 mins)

d.Local examples of interdisciplinary working (20 mins)

i.Cardiology –Dr. Susan Connolly, Cardiology Integrated Care Consultant,

ii.Respiratory –Dr. Sinead Walsh,  Respiratory Integrated Care Consultant,

iii.Diabetes –  Anne Fitzpatrick, Advanced Nurse Practitioner

e.Evaluating impact and benefits for patients: Implementing PROMs as part of the MoC (5 mins)

B.Interactive discussion – What can we learn from teams and how they work in an interdisciplinary approach (All)

a.20 min small group work using post-its and flip charts, 10 min feedback and final questions to panel with discussion

C.Sum up of learning and closing remarks (SOB) (5 min)

Key Learnings/Take away:

• We are implementing an integrated model of care that requires interdisciplinary working to deliver patient centred care which is already demonstrating evidence of positive impact
• We must now continue to build on the work to ensure teams maintain an interdisciplinary way of working, and harness ideas of other roles that should be considered