Clinical Nurse Manager Integrated Care Programme For Older Persons

The person appointed to this post will work as part of the integrated care programme for older persons is to support older adults to access the assessment and intervention that are required to address increasing health needs whilst being maintained in their home.

This role will Co-ordinate the day-to-day functions of the outreach team and work as part of that team as required.

The role involves working across the entire continuum of care for older adults, including community healthcare, networks, and hospitals, as part of a comprehensive ambulatory care strategy.

Provide as a key liaison for referred older adults, facilitating seamless access across Primary Care, Community ICPOP, and Acute services."

• Rapid access assessment

• Rapid access to specialist assessment and treatment pathways Frailty, Falls, Cognitive pathways

• MDT Comprehensive Geriatric Assessment (CGA)

• Access to reablement and rehabilitation after acute illness or injury

• Complex Case management and care co-ordination

• Promotion and support of population health and wellbeing initiatives with primary care

This role entails providing comprehensive support and coordination across the entire continuum of care for older adults within the community healthcare network, it focuses on delivering integrated services that address the diverse health and social needs of elderly patients, from preventive care and early intervention to ongoing management of chronic conditions. The position is a key component of an overarching ambulatory care approach, emphasizing ambulatory services and community-based care to promote independence, enhance quality of life, and reduce hospital admissions. Collaboration with multidisciplinary teams, patients, and their families is essential to ensure seamless care transitions and personalized care plans tailored to the unique needs of everyone.

Health Regions

Six Health Regions have been established within the HSE, on the basis of the geographical boundaries agreed by the Government in July 2019 and they will be operational from 2024.

Each Health Region will be tasked with population specific planning resourcing and delivery of health and social care services for the needs of its unique population. This will result in improved accountability and governance in terms of finance and performance, while also bringing decision-making closer to the frontline.

Health Regions will enable and empower staff to provide services that are:

• Integrated, locally planned and delivered

• Easier to access and navigate

• Available closer to home

Health Regions are geographically based units with clearly defined populations. They align community and hospital services within specific areas. The HSE will retain a strong but leaner central organisation, with more service provision developed at a local level.

The HSE South West health region will manage and deliver all public health and social care services in Cork and Kerry. HSE South West includes all hospital and community healthcare services in the region.

This includes:

• South / South West Hospital Group S/SWHG

• Cork Kerry Community Healthcare CKCH

The Department of Population and Public Health is also now aligned with this health region

Services in the South West health region:

HSE Services working within this region include:

• Acute Hospitals

• Primary care services

• Community services

• Social care services

• Health and social care professionals

• Voluntary sector services

South / South West Hospital Group and Cork Kerry Community Healthcare became part of HSE South West health region on 3rd March 2025 and the transition to the new structures will continue throughout 2026.

Purpose of the post

The post of Clinical Nurse Manager 2 has a pivotal role in service planning, co-ordinating, and managing activity and resources within the clinical area. The main responsibilities are: quality assurance, resource management, staffing and staff development, practice development, facilitating communication and professional/clinical leadership.

(CNM2) plays a key role in managing the care journey of older adults. They support multidisciplinary teams to ensure that older patients receive appropriate care as close to home as possible. Their responsibilities include signposting patients to specialist services available through ICPOP Hubs and outreach and community programs as needed.

Additionally, they lead ambulatory outreach teams focused on delivering specialist care directly in patients' homes to address complex care needs including physio and therapies.

• The post holder will co-ordinate the day to day functions the ambulatory outreach team and work as part of that team as required

• The post holder will ensure that team structures are attended to ensure that the service is consistent with recognized best practice in team functioning.

• While clinical functions are central to the role of liaison, he or she also performs signposting ensuring the provision of a seamless integrated service for the older Adult .

• The post holder will work with staff in Acute Services ICPOP Hubs, Community healthcare networks and GPs to support the management of older person care needs as close to home as possible and to signpost to the most appropriate specialist clinical service including in the specialist hubs when required.

• The post holder will coordinate with the clinical teams in the HUBS, working alongside GPs and Community Healthcare Networks

• They will ensure that the clinical needs of vulnerable older adults are assessed and managed, including in the specialist ambulatory care hub. Additionally, they will support patients in accessing the appropriate care pathways promptly, ensuring a seamless continuum of care between primary care and specialist services.

We welcome enquiries about the role.

Contact Finola Cronin, Operational Lead ICPOP Hub Cork-South City and West Cork

E-Mail: finola.cronin@hse.ie

Tel: 086-0082564

for further information about the role.

Contact Meagan McGlynn at meagan.mcglynn@hse.ie for enquiries relating to the recruitment process.