Integrated Care: The Ultimate Outcome of Healthcare Change Mr. Leo Kearns National Lead For...

Integrated Care: The Ultimate Outcome of Healthcare Change

Mr. Leo KearnsN a t i o n a l L e a d F o r T r a n s f o r m a t i o n a n d C h a n g e

ABF

Free GP Care

Healthy Ireland

Hospital Groups & Community Healthcare Organisations

Universal Health

Insurance

Universal Healthcare

Commissioning

REFORM

A healthier Ireland with a high quality

health service for all

Medical TeamSpecialist Autoimmune TeamRenal TeamRadiology Team

In ward with very elderly patients; 3 nights without

sleep

Renal scan requested on Monday, carried out on Thursday; discharged on Friday with OPD appointment to review renal progress

25 year-old girl, diagnosed at 21 with rare autoimmune condition; triggered acute attacks – infusion treatment

Contraindicated Medication

Prescribed

Acute attack triggered, advised by

consultant to attend ED

After some time, infusion (1 of 2) given, and admitted Sunday night; concern about possible

renal damage

Good outcome; 5 nights in hospital but should have been three; for patient complete confusion as to what was happening between teams; no-one noticed that she hadn’t slept for three days and was becoming highly

distressed; why medication prescribed in first place that triggered attack; why through ED?

25 year-old girl, diagnosed at 21 with rare autoimmune condition; triggered acute attacks – infusion treatment

25 year-old girl, diagnosed at 21 with rare autoimmune condition; triggered acute attacks – infusion treatment

Contraindicated Medication

Prescribed

25 year-old girl, diagnosed at 21 with rare autoimmune condition; triggered acute attacks – infusion treatment

Contraindicated Medication

Prescribed

Acute attack triggered, advised by

consultant to attend ED

25 year-old girl, diagnosed at 21 with rare autoimmune condition; triggered acute attacks – infusion treatment

Contraindicated Medication

Prescribed

Acute attack triggered, advised by

consultant to attend ED

After some time, infusion (1 of 2) given, and admitted Sunday night; concern about possible

renal damage

Medical TeamSpecialist Autoimmune TeamRenal TeamRadiology Team

25 year-old girl, diagnosed at 21 with rare autoimmune condition; triggered acute attacks – infusion treatment

Contraindicated Medication

Prescribed

Acute attack triggered, advised by

consultant to attend ED

After some time, infusion (1 of 2) given, and admitted Sunday night; concern about possible

renal damage

Medical TeamSpecialist Autoimmune TeamRenal TeamRadiology Team

In ward with very elderly patients; 3 nights without

sleep

25 year-old girl, diagnosed at 21 with rare autoimmune condition; triggered acute attacks – infusion treatment

Contraindicated Medication

Prescribed

Acute attack triggered, advised by

consultant to attend ED

After some time, infusion (1 of 2) given, and admitted Sunday night; concern about possible

renal damage

Medical TeamSpecialist Autoimmune TeamRenal TeamRadiology Team

In ward with very elderly patients; 3 nights without

sleep

Renal scan requested on Monday, carried out on Thursday; discharged on Friday with OPD appointment to review renal progress

25 year-old girl, diagnosed at 21 with rare autoimmune condition; triggered acute attacks – infusion treatment

Contraindicated Medication

Prescribed

Acute attack triggered, advised by

consultant to attend ED

After some time, infusion (1 of 2) given, and admitted Sunday night; concern about possible

renal damage

Medical TeamSpecialist Autoimmune TeamRenal TeamRadiology Team

In ward with very elderly patients; 3 nights without

sleep

Renal scan requested on Monday, carried out on Thursday; discharged on Friday with OPD appointment to review renal progress

25 year-old girl, diagnosed at 21 with rare autoimmune condition; triggered acute attacks – infusion treatment

Contraindicated Medication

Prescribed

Acute attack triggered, advised by

consultant to attend ED

After some time, infusion (1 of 2) given, and admitted Sunday night; concern about possible

renal damage

Good outcome; 5 nights in hospital but should have been three; for patient complete confusion as to what was happening between teams; no-one noticed that she hadn’t slept for three days and was becoming highly

distressed; why medication prescribed in first place that triggered attack; why through ED?

Integrated Care

Care pathways and models of care designed and delivered around the needs of patient,

not the system

Integrated Care

Clinical Processes &

Clinical Roles

Care pathways and models of care designed and delivered around the needs of patient,

not the system

Systems and Data

Workforce Planning &

Training

Integrated Care

Clinical Processes &

Clinical Roles

Care pathways and models of care designed and delivered around the needs of patient,

not the system

Systems and Data

Workforce Planning &

Training

Integrated Care

Clinical Processes &

Clinical Roles

Funding Models

Care pathways and models of care designed and delivered around the needs of patient,

not the system

Systems and Data

Workforce Planning &

Training

Integrated Care

Clinical Processes &

Clinical Roles

Funding Models

Care pathways and models of care designed and delivered around the needs of patient,

not the system

Governance & Structures

Performance Metrics

Systems and Data

Workforce Planning &

Training

Integrated Care

Clinical Processes &

Clinical Roles

Funding Models

Care pathways and models of care designed and delivered around the needs of patient,

not the system

Governance & Structures

Performance Metrics

Wider health service and whole of society commitment to

prevention

Achieving this requires a whole of system

approach to change at all levels, sustained over

a number of years

The building blocks for reform are in place

Quality FrameworkIntegrated Care Programmes: Older Person; Chronic; Children; Maternity; FlowHospital Groups, Community Healthcare Organisations, Ambulance ServiceReform at national level to enable delivery system and to develop commissioning capability

A new vision and strategy for people within the health service

Knowledge & Information Strategy

Healthy Ireland Implementation

Finance Operating Model

Activity Based Funding

Service Improvement

By the end of 2015 we will have

a prioritised action plan for reform, drawn

from these programmes, showing key

deliverables for each of next 12 quarters

Leaders make change happen; are you a leader?

Am I a leader?