A New Model of Care: The Integrated Care Programme for Older Persons (ICPOP)
The Integrated Care Programme for Older Persons (ICPOP) was established in 2016 as part of Ireland’s national healthcare reform plan, Sláintecare. It represents a shift from hospital-centric services to a more holistic, community-focused model. The core of integrated care is to provide seamless, coordinated health and social care services, ensuring that older adults with complex health needs receive timely and appropriate support in their own homes and communities. This approach prioritizes early intervention, prevention of avoidable hospital admissions, and a person-centred focus on well-being.
The Role of Multidisciplinary Teams (MDTs)
Central to the ICPOP model are community-based multidisciplinary teams. These teams consist of various healthcare professionals who work together to provide a 'one-stop-shop' for older people with complex needs. The collaborative nature of these teams is essential for breaking down traditional professional silos and ensuring a comprehensive, coordinated care plan for each individual.
Composition of an ICPOP MDT:
- Consultant Geriatrician (provides overall governance)
- Nurses
- Physiotherapist
- Occupational Therapist
- Speech and Language Therapist
- Social Worker
- Dietician
- Other allied health professionals as needed
These teams conduct a comprehensive geriatric assessment, evaluating an older person's medical conditions, functional capacity, and social circumstances. This assessment leads to a personalized care plan that is delivered and coordinated by the MDT. The collaboration between these different professionals is key to the success of integrated care, as highlighted in studies on its implementation.
Key Components of Integrated Care for Older People
Integrated care in Ireland is not a single service but a framework that includes several interconnected components working in harmony. These components are designed to support the older person across different stages of their care journey.
The 10-Step Framework
ICPOP uses a 10-step framework for implementation, building on established good practice within local health and social care services. This approach allows for local innovation supported by national guidance. It focuses on a population health approach, requiring a joint effort between community healthcare organizations and acute hospitals.
Community Healthcare Networks (CHNs)
As part of the wider Enhanced Community Care (ECC) programme, CHNs deliver primary healthcare services within geographical areas of approximately 50,000 people. These networks are designed to:
- Support independent living in the community.
- Coordinate and integrate services to meet health needs.
- Promote collaborative, person-centred care.
- Ensure timely access to services.
Community Intervention Teams (CITs)
CITs provide intensive, short-term care to patients who experience a sudden illness. These teams can facilitate early discharge from hospital or help people avoid hospital admission altogether by providing acute intervention in their own home for a limited period.
The 'Living Well at Home' Initiative
This aspect of ICPOP acknowledges that health is more than just medical treatment. It emphasizes community engagement, including social prescribing and facilitating social connections, which are viewed as essential for empowering older people to age well at home.
Benefits of Integrated Care
The shift towards integrated care models for older persons offers several benefits for individuals, healthcare providers, and the system as a whole. These benefits include improved health outcomes, better patient experience, and more efficient resource use.
Benefits for Older People:
- Timely Access to Care: Integrated care reduces waiting times and ensures older people receive the right care at the right time.
- Person-Centred Care: The focus is on the individual's needs and preferences, promoting independence and dignity.
- Continuity of Care: Coordinated care pathways prevent fragmentation, ensuring a smooth transition from hospital to home and between different care settings.
- Improved Quality of Life: By supporting older people at home, integrated care helps them remain connected to their communities and maintain a better quality of life.
Benefits for the Healthcare System:
- Reduced Hospital Admissions: Early intervention and intensive community support help prevent avoidable hospital referrals and admissions.
- Efficient Resource Allocation: Optimizing care pathways and reducing dependency on acute hospital services leads to more effective use of resources.
- Enhanced Collaboration: Multidisciplinary teams improve communication and trust between different healthcare professionals, leading to better-coordinated care delivery.
Challenges and Future Direction
Despite its successes, the implementation of integrated care in Ireland faces ongoing challenges. Fragmented funding structures, complex professional arrangements, and scaling up local innovations to a national level are persistent issues. Digital solutions, such as shared electronic health records, are crucial for future enhancements, but their implementation requires significant investment. The Sláintecare reform continues to provide the strategic direction, with a long-term vision to expand and mature the integrated care model over the coming years. Efforts are focused on ensuring the model is sustainable and scalable, moving beyond pioneer sites to a more comprehensive national rollout. For example, the HSE's Enhanced Community Care program provides further details and resources related to these initiatives and their implementation: https://www.hse.ie/eng/services/list/2/primarycare/enhanced-community-care/
Integrated Care vs. Traditional Care: A Comparison
To better understand the shift, consider the differences between the integrated care model and a traditional, fragmented approach.
| Feature | Integrated Care (ICPOP) | Traditional Fragmented Care |
|---|---|---|
| Focus | Proactive, community-based care for complex needs. | Reactive, often hospital-based interventions. |
| Service Delivery | Coordinated by a multidisciplinary team (MDT). | Managed by individual specialists or GPs, with less communication. |
| Intervention | Early, preventative, and intensive support at home. | Late intervention, often only after a crisis or hospital admission. |
| Care Setting | Predominantly in the older person's home and community. | Centred around the acute hospital system. |
| Communication | Regular, structured team meetings and shared goals. | Poor communication between different providers and silos. |
| Assessment | Comprehensive geriatric assessment covering medical, functional, and social needs. | Often a narrow, condition-specific assessment. |
Conclusion
What is the integrated care for older people in Ireland? It is a modern, person-centred approach, championed by the HSE's ICPOP, that is designed to support older adults in their own homes for longer. By using multidisciplinary teams, coordinated care pathways, and leveraging community networks, the model seeks to address the complex needs of older people in a holistic manner. While challenges remain, the framework laid out by Sláintecare and the HSE provides a clear path toward a more integrated, efficient, and compassionate system of senior care across Ireland. It represents a fundamental shift in perspective, moving from treating illness to promoting well-being and independence.
