INTEGRATED CARE PARTNERSHIPS


thE NEwly PUBlIShEd INtEgRatEd caRE PaRtNERShIP ImPact REPORt hIghlIghtS thE EaRly ImPactS that haVE BEEN dEmONStRatEd OVER thE laSt thREE yEaRS. OVER thE NExt fEw ISSUES, PIf wIll lOOk at VaRIOUS aREaS Of hEalthcaRE IN whIch IcPS haVE BEEN actIVE aNd PROVIdES SOmE Of thE ExamPlES Of SUccESS tO datE.


INtEgRatEd caRE PaRtNERShIPS IN actION


I


ntegrated care Partnerships (IcPs) were established by the health and Social care Board in 2013, as a key


element of the dhSSPS ‘transforming your care’ strategy.


the IcPs are collaborative networks of care providers, which bring together doctors, nurses, pharmacists, social workers, hospital specialists, other healthcare professionals, local councils and the voluntary and community sectors, as well as service users and carers, to design and coordinate the delivery of local health and social care services.


IcPs focus on key clinical priority areas: diabetes, respiratory, stroke and services for frail older people. Over the last three years £12,747,000 has been invested in services designed and implemented by IcPs across the region: services which focus primarily on - where possible - preventing illness, delivering more care in the community, reducing demand on hospital services and improving patient and carer experience. In this issue we look at end-of-life care.


ENd-Of-lIfE caRE


the challenges which IcPs face with end-of-life care:


• Studies show that the majority of people with a terminal illness would


60 - PhaRmacy IN fOcUS


prefer to die at home, however, approximately 50 per cent of all deaths in Northern Ireland )NI) still occur in hospitals


• 1012 people aged over 85 died in hospital between april- September 2015


• approximately two thirds (9570) of people dying in NI every year would benefit from a level of palliative care during the last year of life but for reasons of diagnosis are excluded


In the South Eastern health and Social care trust (SEhSct), the Peninsula End of life project provided gPs with the opportunity to have dedicated time to discuss palliative and end-of- life cases with colleagues, and to access training focussing specifically on clinical management of palliative care needs.


the pilot was delivered between may 2014 and may 2015 and involved four gP practices in the ards Peninsula area.


gPs attended monthly multidisciplinary meetings to identify and discuss palliative and end-of-life cases, to target care, advice, and proactive planning to specific patient groups and their carers to avoid unnecessary hospital admissions. gPs


from the practices involved also participated in two days of training.


the lcg provided funding to remunerate gP practices for time taken out of practice to attend these sessions. as a result of the provision of adequate medical care in the community, the number of emergency admissions to hospital/hospice decreased by 64 per cent in 2014/15. an evaluation report has been completed and discussions are ongoing to further develop the project.


In the western health and Social care trust (whSct), meanwhile, an enhanced day hospice pilot has given patients and families access to a specialist palliative care service on an outpatient basis in the northern sector of the western area.


IcPs in the whSct secured funding for a medical officer and a nurse to enhance the existing day hospice team at foyle hospice to provide specialist palliative medicine review and nursing assessment for new patients, and a review of existing patients to advise on how to best manage symptoms and other support. Patients could also access respite from home for a day a week to socialise with others and take


part in other activities provided by foyle hospice.


from September 2015 until march 2016, 48 new patients were assessed and 201 existing patients were reviewed by the team. thirty-two people took up the opportunity to create an advanced plan and 19 of these people established and documented preferences for their end-of-life care.


'compassionate communities' is a public health approach to end-of-life care, which encourages communities to support people and their families, who are finding life difficult due to chronic or end-of-life conditions. a compassionate communities pilot was delivered through the IcP and led by foyle hospice in the waterside area of derry/londonderry. the pilot was a partnership between hillcrest house and caw/Nelson drive community groups and the three gP practices based in waterside health centre from july 2015 to march 2016.


the aims of the project were to reduce social isolation and to enable people to remain living independently at home if that is their wish. to date, fifteen volunteers have been trained as befrienders and 16 people have been referred for support. •


caSE StUdy k


atherine is a 78-year-old woman living on her own in the waterside area. She suffers from numerous medical conditions, which means she tires easily and her mobility is severely restricted. She is matched to Pauline, a compassionate communities volunteer.


katherine explains that she feels reconnected to her community because of Pauline's visits and that it reduces the loneliness she experiences and is something she enjoys.


'you may have got up in the morning and think 'not another day', says katherine.


'then you realise she's going to come in the afternoon and that suits fine. It's something to look forward to - a wee cup of tea and a chat and finding out what's happening.'


Pauline visits katherine every monday for an hour or two and is from the local area. She tells how she was a bit worried before the first meeting about whether they would get along.


Now she feels there is a friendship growing between them and that they were well matched at the beginning of the befriending process.


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