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Reading: Implementing integrated care for older people in Ireland; inside the black box

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Implementing integrated care for older people in Ireland; inside the black box

Author:

Patrick Harnett

Integrated Care Programme Older Persons (Health Service Executive and Munster Technological University, Ireland, IE
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Abstract

Introduction: The Integrated Care Programme for Older Persons (ICPOP) in Ireland was established in 2016 to design and test a new model of integrated care for older persons. ‘Barometric’ indicators such as emergency department attendance, self-referrals, and trolley waits for those aged 75+ indicated poorer outcomes rooted in this mismatch and fragmentation. Integrated care was proposed as a policy solution despite limited systemic examples in practice. The programme faced two challenges. Integrated care is polymorphous, with different objectives among different actors and stakeholders requiring it to be conceptually grounded. More critically, implementing systemic change in health systems is notoriously difficult. Adopting an Action Research methodology, a programme to design and test a systemically scalable model of integrated care was developed.

A literature search addressed two simultaneous questions:

(1) What were the key ingredients required to integrate care for older persons?

(2) What is a more-effective methodology to support systemic implementation?

Aim and theory of change: Consensus on the first, but not on the second, and drawing on the balanced socio-technical perspective of Greenhalgh et al. (2004), led to a research hypothesis that a methodology incorporating ‘soft edges’ and ‘hard edges’ identified in the literature review would address this ‘wicked problem’ in practice. This included attending to five key elements: Personal/ Professional, Culture, Process, Leadership, Organisational.

Practice change: In multiple rounds of collaboration with practitioners, a resultant 10-step framework was evolved. This functioned as both conceptual model and an implementation roadmap. This was mobilised at thirteen pioneer sites in tandem with a choreographing methodology, which included a deep and active programme of engagement in loco, with a core principle of ‘direction without dictat’.   

Timeline: A mix of quantitative and qualitative data was collected over two years, including surveying the utility of the framework to participant actors and capturing and presenting timely data on emergent care-process performance.

Highlights: Pioneer sites demonstrated fidelity to the model, improving access and efficiencies. Site specific changes included bed use saving (1,000 bed days), reduced length of stay (2-5 days) and improved access (49% seen within 7 days), and growth in multi-disciplinary teams (465 posts) and age attuned pathways (45). The framework has shown a high degree of utility to the local clinical and managerial leaders tasked with implementation.

Discussion and conclusions: At a macro level, the use of and contents of the 10 Step Framework as both a concept map and to augment implementation reinforces the need for an accompanying agile mixture of emergent, negotiated and planned approaches as reflected in original work by Greenhalgh et al (2004).

Whilst the central importance of the 10 Step Framework is as a conceptual anchor, the framework needs to be given life with surrounding implementation methodology. This bridges the intent-realisation gap in systematic implementation within a complex adaptive system that facilitates balance between latitude and prescription, emergence and fidelity. This methodology facilitates implementation, moving from complex challenge to complex adaptation.  

How to Cite: Harnett P. Implementing integrated care for older people in Ireland; inside the black box. International Journal of Integrated Care. 2022;22(S3):481. DOI: http://doi.org/10.5334/ijic.ICIC22253
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Published on 04 Nov 2022.

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