Shifting acute care delivery from hospitals to homes in Ireland
- Overreliance on institutional services and lack of community care alternatives.
- Long waiting times for acute care services and frequent shortages of hospital beds.
- Community-based acute care services delivered by mobile nursing teams were introduced by Caredoc, a private nonprofit organization contracted by the Irish Health Services Executive.
- First-hand insights of providers enabled identification of services delivery challenges and supported development of relevant solutions.
- Supportive senior management generated momentum for change and helped secure necessary approval for activities from authorities.
- Stakeholder engagement was described as time consuming, but crucial to success.
- Electronic medical records and new technologies facilitated the creation of a simple, connected and user-friendly service.
- Training for nursing staff was important for establishing the necessary clinical competencies to deliver acute care services in home settings.
Lack of community care services created overreliance on institutional care, causing long hospital waiting times and frequent shortages of hospital beds. With growing care needs linked to an ageing population and increasing chronicity, there was mounting pressure to address what was perceived as an “acute care crisis”.
Caredoc, a private nonprofit organization with a long history of providing out-of-hours medical care in Ireland, developed the Community Intervention Team Model to expand Caredoc services in the area of Carlow-Kilkenny to include community-based acute care. Newly-introduced Community Intervention Teams are composed of experienced, specially-trained nurses who work with hospital providers, general practitioners and patients to provide acute care services in home settings, allowing patients to return home from hospital sooner. Hospital providers identify eligible patients for early discharge via a specially-designed, simple and user-friendly clinical algorithm. Providers then complete e-referrals for eligible patients, triggering a phone call from the Community Intervention Team to discuss each referral. Accepted patients are then visited by the Community Intervention Team to develop a personalized care plan and prepare patients to return home. Patients are then released under care of the Community Intervention Team, usually for a period of 72 hours but as long as medically needed. Community Intervention Teams are fully equipped with necessary medical supplies, vehicles and electronic tablets by Caredoc. Electronic medical records, instantly updated during home visits, allow all providers across care settings to access and share information as needed. Examples of services now managed by Community Intervention Teams include intravenous therapy, catheterization, medication reconciliation and hospital discharge support to postoperative patients or patients with chronic disease.
Fully implemented and scaled up
Senior nurses working within Caredoc leveraged their technical insight and authority to pitch the initiative to Caredoc directors who proved supportive of the proposal. A multidisciplinary working group was convened to plan the initiative and support and funding from the Irish Health Services Executive was secured. Extensive and persistent stakeholder engagement helped secure widespread support and cooperation from providers across care settings. Management and delivery of the service is run by Caredoc according to agreed contract terms with the Health Services Executive. Community Intervention Teams are composed of nine acute care nurses who work together to care for patients in cooperation with external providers.
Community Intervention Teams have been reported as successful and the Health Services Executive has incorporated the service into its annual budget. Community Intervention Teams provided nearly 4000 interventions between 2012 and 2013, averting 2300 hospital bed days and 215 ambulance trips. Further, patient satisfaction surveys showed 100% of respondents were pleased with the service and believed care to be high quality, flexible to needs and convenient. Clear and simple referral services, effective use of information technology and cooperative teamwork across care settings have been credited to the delivery of a streamlined, high-quality service. Building on the success in Carlow-Kilkenny, Caredoc has extended the service to other areas and continues to scale up activities.
This case was prepared as part of a larger effort by the WHO Regional Office for Europe and published (2016) in the document, "Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region".
© Copyright World Health Organization (WHO), 2016
The methodology used for the development of this case is slightly different from the templates used on the IntegratedCare4People web platform, in particular in the analysis of enabling factors and barriers to change.
Health care provider