The integrated care hub and primary care centre in Bray, Co Wicklow, aims to keep care in the community, which is the key principle of Sláintecare. Niamh Quinlan recently visited the facilities and spoke to staff.
The national enhanced community care (ECC) programme, a Sláintecare initiative, aims to enhance and increase community health services and relieve pressure on acute hospital services. As part of the ECC programme, the Bray integrated care hub and primary care centre was officially opened in May.
The ECC programme’s objectives include building health and social care services at community level, implementing community specialist hubs including integrated care programmes for older people, and developing new primary care centres.
The primary care centre mainly delivers primary care, mental health and community services in one modern facility, while the integrated care hub provides a base for the integrated care programme for older people and chronic disease management services.
Speaking outside the hub in Bray on 27 July, Minister for Health Stephen Donnelly said: “This isn’t a theory, it’s not the launch of a strategy, this is something that’s already happening.”
The ECC programme is a key reform programme with an investment of €240 million to develop care in the community.
This “transformational programme” will include 96 community healthcare networks, 30 community specialist teams for older persons, 30 community specialist teams for chronic disease, and 3,500 additional staff when fully implemented, according to the HSE.
The ECC programme will also “empower” GPs, health and social care professions, and nursing leadership at a local level to “drive integrated care delivery” and support transition from hospitals to the community.
Integrated care
A central objective of the primary care centre and integrated care hub in Bray is to allow clients to access integrated care facilities close to their home and in a more comfortable environment than acute care.
Although the buildings are relatively new, the diabetes team in Bray has been operating for over 20 years. The clinic is now based in the hub as part of the ECC programme.
Diabetes Clinical Nurse Specialist Ms Joanne Lowe said: “Obviously, with the hub coming along, we will have more services in one place. So when people with type 2 diabetes come along, they will be able to access diabetes nurses, dieticians, and the podiatrist as well. All the care will be available here. We see people really in a timely manner, and we’re able to see them close to their home.” The diabetes team sees approximately 200 patients each month.
The investment in primary care hasn’t always been as speedy as we’d have liked it. [But] in recent years, the investment has been really, really advanced
As part of the ECC programme, the centre and the hub are also able to provide home or domiciliary care, such as occupational therapy, physiotherapy and speech and language therapy services.
Senior Speech and Language Therapist Ms Fiona Craven said there was an identified need in regard to provision of at-home care.
“There was a bit of a service provided through the local hospital,” she added. “But again, with Sláintecare what we’re trying to do is move those services outside of the hospital and into the community.”
The physiotherapy service can also provide mobility equipment for use in the homes of clients.
At the breastfeeding support group and lactation consultant clinic, health services and supports are provided to new mothers. Lactation Consultant Ms Allison Reynolds commented: “I love hearing in primary care that we can be really accessible to mums, which isn’t always the case for our colleagues, maybe in the maternity hospitals. I have access to the whole medical team here with our primary care team: We have our dietitians; our community medical doctors; our GPs; our public health nurse team. We are in a better position than a lot of other counties in Ireland. So we love that we can be accessible.” Mothers may be referred by their GP, public health nurse, maternity hospital or by self-referral. The breastfeeding groups are mainly organised through WhatsApp.
‘Future-proofing’ community care
At-home mobile devices and artificial intelligence (AI) technology will help ease pressure on GPs and acute hospitals, according to Consultant Cardiologist at the Bray integrated care hub, Dr Matthew Barrett.
Dr Barrett demonstrated how the hub is monitoring at-risk patients with two key pieces of technology: The Alive-Cor KardiaMobile, a small device which connects to a phone and can record an ECG; and the Caption AI echocardiogram ultrasound.
The cardiology unit recently received funding from the HSE digital transformation fund to supply a library of 60 Alive-Cor KardiaMobile heart rhythm monitors. Patients take home a portable heart monitor and conduct an ECG recording “any time you get palpitations or maybe a few times a week” for three-to-six months, according to Dr Barrett.
Once a day, the cardiology team in the Bray hub will log on to the system that stores the results in order to monitor the patient.
Dr Barrett said: “The amount of work you take out of the system in terms of physiologists who would have to be the ones to fit you with a heart monitor, leave it on you for 24 hours, and [the patient] may not have palpitations at the end of [that] period. And we’re always kind of wondering: Did we miss something?
“Whereas if you have this for a few months, take a few little recordings, we can line up when you’re having your symptoms.”
The Caption AI echocardiogram device guides the person doing the echocardiogram to conduct the exam and take accurate pictures on the ultrasound.
Prevention
Keeping healthcare in the community helps to relieve pressure on acute facilities.
According to the HSE: “It is projected the ECC programme can achieve a 20 per cent reduction in over-75s admitted to emergency departments in hospitals served by the community specialist teams, freeing up critical acute care resources once the programme is fully rolled out in 2023.”
PARC – bridging primary and secondary mental healthcare
The positive advanced recovery connections (PARC) project aims to reduce waiting lists by bridging the gap between secondary and primary care.
The PARC pilot programme in the Bray primary care centre provides registered mental health advanced nurse practitioner (ANP) clinics, which provide timely access to psychosocial assessment and mental health nurse interventions while working with secondary care and signposting to community supports. The programme supports people with mild-to-moderate conditions.
According to ANP in Mental Health, Ms Anne Cunningham, the establishment of these specialist clinics has meant there is “no waiting list for psychiatric assessment, which I think is kind of unheard of”.
“[There is also] no waiting list for ANP specialist psychosocial interventions…. You get seen and you’re offered the intervention the following week. We know that quantitatively and qualitatively, this works.”
According to Community Healthcare East, 60 per cent of patients who took part in PARC recovered, 28 per cent improved and 12 per cent “remained the same, but reported they benefited from having a safe place to talk”.
Consultant Psychiatrist with the Bray community mental health team, Dr Edyta Truszkowska, said: “The psychosocial interventions are the key. They help us to reduce acute presentations to hospital, admission to hospitals and also reduce the numbers of active mild and moderate patients within the cohort of secondary mental health, which gives us time to focus on those on the more severe end of mental illness as well.”
Clients feel supported after discharge, according to one service user. “And because of the way PARC works, when you’re discharged, you’re not completely out of the system,” she said. “You can ring at any time and come back in, so you’re not going onto a waiting list. And that makes a huge difference for patients as a backup in facing moving on from secondary mental health services.”
Ms Cunningham also told the Medical Independent that the PARC service is open to linking with other primary care services, such as counselling in primary care and primary care psychology, so that patients on a waiting list have access to care in the interim.
She added that the pilot will soon be implemented as a service in Bray following the completion of administrative agreements. “…. Then we could look at how do we bring this into other areas. And I know the health service is very keen.”
Ms Martina Queally, Chief Officer of Community Healthcare East, said: “The big trick with Sláintecare is really prevention [and] adopting much earlier intervention, because we know about 40 per cent of our admissions are from diseases that are preventable.”
The x-ray facility at the primary care centre takes GP referrals or presentations such as long-standing pain or long-lasting coughs. However, trauma- and fracture-related x-rays are referred to acute care.
“I’d say if you ask the GPs, the majority of the diagnostic imaging that they request is ultrasound and x-ray,” said Clinical Specialist Radiographer Ms Shóna Daly.
The centre can relieve a significant workload from the acute system, she said, and allow hospitals to focus more on their inpatient care.
The hub facilitates early supported hospital discharge, which can free up beds for those who require acute care, according to the Operational Lead for the integrated care programme for older people, Ms Helen O’Riordan.
“The enhanced community care objective is to shift the care away from that hospital-centred model, back out to the community wherever possible, and this is a great example of that,” she said.
The integrated care programme for older people provides community-based assessment and rehabilitation for older people experiencing falls, frailty, and dementia. The current programme provides an interdisciplinary short-term intensive service focusing on optimising the health of the older person. The team works in collaboration with colleagues in the acute hospital sector, primary care and general practice.
These rooms are set up in a way that we can interchange in terms of how we do our assessments
The team typically provides a six-week rehabilitation service close to the patient’s home and is comprised of a physiotherapist, occupational therapist and consultant geriatrician.
The aim is to support “frailer patients living at home by providing a comprehensive assessment and targeted interventions to improve mobility and function.
Access to our service facilitates early discharge from the acute hospital setting and reduces the need for patients to attend emergency departments.”
The consultant geriatrician posts are shared across hospitals and the community, further bridging the services.
Similarly, consultants in the chronic disease programme for pulmonary care are working in both the integrated care hub and in acute hospitals.
Investment
According to the HSE, €240 million has been allocated to fund 3,500 additional staff to advance the ECC programme, with an estimated 1,600-1,700 staff already in place, according to Minister Donnelly.
Public investment in community-based healthcare facilities is “really, really valued”, commented Chief Officer Ms Queally.
“Having buildings like this and rooms like this actually facilitate a lot of this work,” she said. “The investment in primary care hasn’t always been as speedy as we’d have liked it. [But] in recent years, the investment has been really, really advanced. And it has made such a difference in terms of the ability to just do work like this. It’s really important.”
Many of the rooms in the primary care centre are multifunctional. The centre and hub also provide spaces for multidisciplinary teams to work closely together.
In the primary care centre, Senior Physiotherapist Ms Eavan Lennox highlighted the interdisciplinary work undertaken with colleagues in occupational therapy and speech and language therapy in the centre and on domiciliary visits.
“We’re all in an office upstairs and we can talk to each other very easily,” she told the Medical Independent (MI).
“In a local centre like this, you’re not trying to make phone calls or trying to catch someone; they’re in the same office.”
Consultant Geriatrician Dr Nichola Boyle informed MI it was not a coincidence that the physiotherapy assessment suite and the occupational therapy assessment suite had a connecting door.
She said: “These rooms are set up in a way that we can interchange in terms of how we do our assessments.”
Investment has facilitated development of health technology in the community with assistance from the HSE digital transformation fund.
The fund has allowed the cardiology unit in the integrated care hub to purchase 60 ECG monitors for patients to use at home.
A pilot project for primary care mental health has also been established.
The positive advanced recovery connections project provides “a bridging service” between primary and secondary care with the introduction of registered mental health advanced nurse practitioner specialist clinics, supported by a consultant psychiatrist and the community mental health team.
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