Creating conditions for change and integration

Dr Stanley Miller, HSE National Clinical Lead for Respiratory, was one of several speakers at the Irish Thoracic Society Annual Scientific Meeting 2023 who emphasised the importance of “looking towards the future” and “creating the conditions for change” in the way respiratory care is delivered in Ireland. During a panel discussion on integrated care, Dr Miller told attendees that “the days of the patient going to the acute hospital for everything are over”. He described the myriad ways that integrated care hubs and the chronic disease management (CDM) programme are “empowering people to live well” with chronic disease. He added that these care pathways also “fit nicely” into the Sláintecare ethos of “the right care at the right place at the right time” by providing care closer to the patient’s home and addressing the “whole person”.

The meeting heard that chronic diseases in Ireland “create a definite signal within acute healthcare”. Dr Miller described the myriad ways in which integrated hubs and primary care are changing the way these patients are treated. He stated that 89 per cent of care is now provided by GPs and practice nurses, and compared the 29 million patient interactions that now take place annually in general practice to the 0.6 million that take place in acute hospitals, 1.5 million in emergency departments, and 3.5 million in outpatient departments. Dr Miller provided a general overview of the CDM programme, in which 800,000 patients are now enrolled.

“As patients participate in the CDM programme, we’re seeing a reduction in smoking habits, reduction in obesity, improvements in physical activity, and a reduction in risky alcohol intake…. The ideal is that our GPs are identifying symptoms and risk factors. They’re then conferring diagnosis with spirometry, and then they’re implementing treatment. The only reason they need to refer on to specialty care is if they need a helping hand.”

Describing that helping hand, Dr Miller also provided insight into the multidisciplinary, person-centred, and holistic structures within integrated hubs that provide “episodic care” as required from a wide range of professional disciplines, such as physiotherapy, speech and language, palliative care, psychology, and dietetics. Health and Social Care Professions Lead Ms Olga Riley, who joined Dr Miller on the panel, told attendees that a total of 26 health and social care professionals “work within the respiratory remit” to provide this optimal level of care away from the acute hospital setting.

“We have a good relationship with all the advocacy groups,” Dr Miller added about the hubs. He elaborated on the collaboration that takes place across the array of disciplines and groups to support patents in exercise maintenance, weight and medication management, peer support, nutrition, metal health, and many other areas of disease management.

“Our consultants are working across both community and hospital providing end-to-end care. They’re collaborating with the GP and the specialist MDT [multidisciplinary team] in the assessment and management of complex chronic disease in the community setting. They’re giving timely access to specialist opinion and providing leadership and innovation in integrated care.”

Dr Miller then gave an account of the growing number of hubs across the country and the shared learning, interprofessional communication, and positive impacts that are ongoing. He also outlined latest, updated care pathways for chronic obstructive pulmonary disease and asthma, and how these pathways are already positively impacting waiting lists in acute hospitals, patient care, and consultant workloads.

“We’re empowering our physiotherapists and nurses to be the respiratory specialists,” Dr Miller said during an account of the new system of care delivery. “Out of 316 patients, I only needed to have an interaction face-to-face or virtually with 40…. For the remaining 276, we were able to give advice, the nurses saw them again, we gave advice back to the GP, and we continued to discuss their care in a MDT setting. Ultimately, this approach diverted 276 patients away from the traditional consultant-acute hospital respiratory clinic.”