The Care Continuum

As integrated care programmes are implemented all over the country, the Irish Dental Association spoke to IFIC Ireland Co-Director, Dr Áine Carroll about what integrated care is, and how oral health might fit in this vision of our health service. To read the journal of the Irish Dental Association click here!

Dr Áine Carroll is a consultant in neurological rehabilitation at the National Rehabilitation Hospital (NRH) in Dublin, and Professor of Healthcare Integration and Improvement at UCD. She credits her background in rehabilitation medicine as the starting point of her interest in integrated care: “In rehabilitation medicine we work across boundaries and in multidisciplinary teams; we stay with our patients from onset of their illness for the rest of their life. That continuum of care is very important to us”. This dedication to a team-based approach to care, along with an interest in how health services work, and how they can be changed for the better, led Áine to a post as clinical lead for the National Rehabilitation Programme, part of the HSE’s National Clinical Programmes. She eventually succeeded Dr Barry White as National Director of Clinical Strategy and Programmes in 2012: “The clinical programmes were set up to look at quality, access and value: quality of care, access to the right care at the right time in the right place by the right team, and value for money”. While the National Clinical Programmes were very successful at developing disease-specific care pathways, changing demographics, and changing demands on the healthcare system, mean that other approaches are needed: “We have an ageing population, which means that we have got people living longer with multiple morbidities. We’ve got increasing chronic diseases, we’ve got the long-term consequences of obesity and alcohol consumption. We also have issues over finance; we never seem to have enough money for health and social care. We have got significant issues with certain populations being excluded from health and social care. Deprivation or poverty is a really big issue. We deliver our services in a fragmented manner. They are not person centred and they are extremely difficult to navigate. It shouldn’t be like that”. From these observations, and an international evidence base, comes the concept of integrated care.

Delivering healthcare differently

For Áine, integrated care is what happens when we think about how we can deliver healthcare differently, and is essentially very simple: “Our vision for integrated care was that we would have person-centred, co-ordinated care”. The programmes sit within the overall framework of Sláintecare, the Government’s 10-year plan to reform health and social care services. Sláintecare includes a focus on moving services into the community: “We are hospital obsessed in this country. We judge our health system by waiting lists, by trolley counts, instead of actually asking: what do we need to do to stop this happening in the first place? With Sláintecare, we have this expressed desire to move services into the community, but that will require a fundamental change in how we provide our services, and in how we train and educate our staff”. This doesn’t mean taking resources from hospitals, but rather means adequate parallel investment: “We need GPs to be properly resourced, we need the community teams to be properly resourced. We need the third-sector organisations, such as home care organisations, to be properly resourced. All of those things that will keep people well at home need to be resourced. That does not come cheap”. Also key is the realisation that a myriad of factors contribute to good health: “To remain well at home requires good housing, good transport, so it really does require a full governmental commitment”.

Pilots

Integrated care is most needed by those with multiple morbidities, such as frail older people, people with chronic illnesses, or patients with complex acquired disabilities such as those Áine cares for in the NRH. Therefore, the first integrated care programmes were for older people, chronic disease, patient flow, and children’s health: “[The intention is that] services wrap themselves around the needs of the individual, rather than the expectation that the individual would be able to navigate their way around how we currently organise our services”.

For the integrated care programme for older people, a 10-step framework was developed setting out the different steps required, from identifying the care needs of the older population in a particular area, to developing person centred care pathways that use a case management approach to co-ordinate the supports needed by each individual, to ongoing audit and monitoring of the programme. This was tested in pilot sites around the country, and Áine says that they are now making a real difference. She mentions the programme in Waterford, led by geriatrician Dr John Cook: “They’ve got a clinical hub up and running and they are showing the benefits in terms of reduced admissions, reduced readmissions, and good evidence of people being managed at home, getting access in a timely manner to comprehensive assessment and support dependent on individual needs. It’s an excellent example of a how things should be done”.

Of course, it’s not a one size fits all approach; integrated care programmes by their very nature need to suit the needs of specific areas and populations, and also need to be reviewed to reflect how those needs change over time: “You have to analyse as you go along, tweaking and being flexible, because you can’t just take a 10-step framework and put it anywhere. It has to be interpreted locally because what works in Donegal is not going to work in inner city Dublin”.

Getting all stakeholders on board, and maintaining that engagement, is particularly important in a strategy that, as Áine says, does not deliver fast wins: “We’re starting to see the benefits, but you need to give it time to embed, to deliver the benefits, whereas we live in a society that demands immediate response”.

In a world where resources can depend on the vagaries of election cycles and short attention spans, this can pose particular challenges, but Áine says it’s something they’re aware of: “There’s lots of things I wish weren’t the case – the short political cycles, the annual service planning processes for things that should be multiannual – but at the end of the day it is as it is. You have to get on with the work that needs to be done while being aware that these key stakeholders that you are reliant on to continue to support your programme – including patients and carers – need to be kept in the loop. To be true to the process of co-design is really important, and the programmes were built on that philosophy: ‘nothing about me without me’”.

Challenges

So what are the other challenges that have to be surmounted to bring about significant change?: “Our biggest challenge is our ICT [information and communications technology]. If a crisis happens, how can you respond if you can’t share information to find out what’s available in that local area? It’s a fundamental enabler of integrated care that we simply do not have”.

Changing mindsets within services is also crucial: “We still work in siloes, whether organisational or professional, and [changing] that is about taking the time to develop relationships across those different areas. What we discovered was that people didn’t know each other; they may have communicated by email or on the phone, but they’d never actually met to reach a shared understanding, and develop an appreciation, of what the other does, of the challenges that they’re facing. Where you take the time to do that, we found that transformative”. Money is, of course, always an issue, but Áine says it’s not the be all and end all: “What people want is joy in their work and to get pleasure out of seeing people get better and improve. With my clinical colleagues, if I put it to them that if we do this thing, it will result in better outcomes for patients, I’ve never had anyone say no”.

Role of dentistry

So where does dentistry and oral care fit into all of this? Unfortunately, in a formal sense, it doesn’t yet, but Áine acknowledges its importance, and with talks hopefully about to begin on the new oral health policy, there may be a real opportunity to integrate oral health into the general health of the nation: “If you think about your continuum from cradle to grave, oral health is extremely important. It’s exactly the same principle. When you need to have something done, do you have access in a timely manner to the treatment that you require? And the answer is, unless you’re paying privately, no you don’t. So what are the knock-on consequences of that in terms of the development of caries and additional procedures that you probably wouldn’t require if you had the right treatment at the right time, in the right place? So you could look at it in any phase of someone’s life cycle, and in terms of members of the multidisciplinary team, the dentist has got to be right there”.

Taking it to the next level

There is much still to be done, and Áine’s new role in UCD is about taking the best international evidence and making it available to those who are trying to implement an integrated care approach in their service. In particular, the role of the International Foundation for Integrated Care (IFIC) has been crucial: “IFIC was a huge support to me in setting up the integrated care programmes in the first place. We recognised that we need to be able to help Irish teams in Ireland to do the work that needs to be done, so IFIC were very agreeable to set up an Irish hub and that’s what we’ve done”.

IFIC Ireland was launched last year, and is very much open for business: “We have three main pillars: education and training; research and evaluation; and, knowledge mobilisation. Underneath those are a variety of activities, such as webinars and workshops. We have credible experts around the globe who can help with different aspects, and we’ve our own internal expertise now. Whether it is in the very early planning stages, whether it is in the design stage, whether it is in the evaluation space, we can help”.