Hsemw Staff Nurse, Cardiac Rehablilitation

In line with Sláintecare (2017) and the Department of Health’s Capacity review (2018), a shift in healthcare service provision is now required to place the focus on integrated, person-centred care, based as close to home as possible. In order to enable this, the Integrated Care Programme for the Prevention and Management of Chronic Disease (ICPCD) is supporting the national implementation of a model of integrated care for the prevention and management of chronic disease as part of the Enhanced Community Care Programme (ECC). The Model of Care for the Integrated Prevention and Management of Chronic Disease has a particular focus on preventive healthcare, early intervention and the provision of supports to live well with chronic disease.

The investment in the ECC programme will be delivered on a phased basis with a view to national coverage being achieved within a two- to three- year period. Three priority areas have been identified as follows:

The focus is on providing an end-to-end pathway that will reduce admissions to acute hospitals by providing access to diagnostics and specialist services in the ambulatory care hubs in a timely manner. For patients who require hospital admission, the emphasis is on minimising the hospital length of stay, with the provision of post-discharge follow up and support for people in the community and in their own homes, where required. A shared local governance structure across the local acute hospitals and the associated CHO will ensure the development of a fully integrated service and end-to-end pathway for individuals living with chronic disease.

The ECC Programme is underpinned by a set of key principles including:

• Eighty percent of services delivered in Primary Care are through the GP and CHNs;
• Identifying and building health needs assessments at a CHN level (approximate population of 50,000) based on a population stratification approach to include identification of people with chronic disease and frequent service users, thereby ensuring the right people get the right service based on the complexity of their health care needs;
• Utilisation of a whole system approach to integrating care based on person centred models, while promoting self-care in the community;
• The Older Persons and Chronic Disease Service Models set out an end to end service architecture for the identification and management of frail older adults with complex care needs and people living with chronic disease;
• Learning from, and delivering services, based on best practice models and the extensive work of the integrated care clinical programmes to date, particularly in the areas of Older Persons and Chronic Disease;
• Embed preventive approach to chronic disease into all services;
• Availability of a timely response to early presentations of identified conditions and the ability to manage appropriate levels of complexity related to same in the community;
• Resources applied intensively in a targeted manner to a defined population, implementing best practice models of care to demonstrate the delivery of specific outcomes and sustainable services; and,
• The need to frontload investment, coupled with reform to strengthen community services.

The role of the Staff Nurse Cardiac Rehabilitation will differ according to the needs and configuration of existing services at the local level. The successful candidate will work in community cardiac rehabilitation services and as part of the team working to integrate ambulatory cardiac rehabilitation care across the hospital and community services and will work with colleagues across these services to develop and implement ambulatory care pathways and to manage cardiovascular disease, and associated co-morbidities, within the community setting, where appropriate.

Ambulatory care hubs are sites identified outside of the hospital setting that will provide access to specialist services within the community. Each hub will be affiliated with a local hospital and will serve a population of approximately 150,000 and will focus primarily on the prevention and management of chronic disease. These hubs will be established to support the provision of care closer to home and to facilitate ready access to diagnostics, specialist services and specialist opinions in order to enhance the delivery of patient-centred care, support early intervention and avoid hospital admission, where possible.

Each site will have a suite of alternative outpatient pathways, support from multidisciplinary Chronic Disease Specialist Teams and access to diagnostics including ECHO and NTProBNP testing, radiology and laboratory testing as well as a Consultant Cardiologist supporting the service to ensure the provision of the right care, in the right place, at the right time.

The Integrated Cardiology Service will support:

• A holistic, multidisciplinary approach to the care of individuals with cardiovascular disease;

• Provision of a reformed outpatient service that utilises telehealth and other ICT measures to facilitate more effective and efficient delivery of care;

• Reduced waiting times for patients for hospital-based outpatient services;

• Timely access to specialist services and specialist opinion for patients with cardiovascular disease;

• Early intervention pathways/ rapid access clinics for acute, chronic or newly presenting cardiovascular conditions;

• Development of pathways for the management of chronic conditions. The early assessment and implementation of pathways that will support GP-led primary care, efficient discharge back to the community where appropriate and reduce the need for repeated hospital-based outpatient reviews;

• Provision of oversight and implementation of self-management support services for cardiovascular disease, including cardiac rehabilitation in the ambulatory care hubs;

• Facilitating access and reporting of non-invasive cardiology testing e.g. ECHO or NTProBNP testing for GPs; and,

• Providing improved integration of early discharge and potential admission avoidance programmes

The person appointed to this post will work as part of the Integrated Community Cardiac Rehabilitation Team which is a newly developed service within the overall cardiology service in the local acute site.

The post holder will work as part of a multidisciplinary team to deliver a comprehensive cardiac rehabilitation service to the locality, providing a multi-disciplinary and multi-agency approach to maximise patient function, wellbeing and self-care planning through evidence based care.

The Staff Nurse will work to reduce the readmission of patients with CR qualifying diagnoses (e.g. HF) by providing transitional support, follow up and timely access for this patient population.

The post will be full time based in the ambulatory care hub in the community setting.

As outlined above, the need to reform the healthcare services in Ireland in order to provide a more sustainable, integrated and patient-centred approach has come to the fore in recent health policies and strategies. Integrated care requires health and social care services to work together across different levels and sites in order to provide end-to-end care that meets patient need.

The Staff Nurse will assess, plan, implement and evaluate care to the highest professional and ethical standards within the model of nursing care practiced in the relevant care setting (i.e. Cardiac Rehabilitation). The staff nurse will provide holistic, person centred care, promoting optimum independence and enhancing the quality of life for service users.

Informal Enquiries to:

Ms. Carmel O’Connor - Assistant Director of Public Health Nursing

Tel: 087- 2939051

Email:carmel.oconnor4@hse.ie

Ms. Mary McCarthy Cardiac Rehabilitation Coordinator

Tel: 0874861948

Email: mary.mccarthy17@hse.ie