For informal enquiries please contact:

Name: Breege Donoghue, General Manager, Older Persons Services

Email: breege.donoghue@hse.ie
Tel: 0868069890

The Operational Team Lead Integrated Care Older Persons will play a key role in implementing the Service Model for Older Persons for the IHA. While not directly involved in delivery of care, they will have experience in the delivery of older persons’ services that helps to manage a patient's care journey and signpost patients to the correct service, coordinate patients' treatment plans, connect them with health care professionals, and evaluate their progress 

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. The post must be congruent with the requirement of Sláintecare, HSE National framework for the Prevention and management of chronic disease and the Enhanced Community Care Business case. 

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. As described in the Sláintecare report (2017), integrated care involves: 

• Ensuring appropriate care pathways are developed with a focus on person-centred service planning to ensure services are built around patients; 

• Supporting timely access to all health and social care services according to  medical need; and, 

• Patients accessing care at the most appropriate, cost effective service level with a strong emphasis on prevention and public health. 

Implementing integrated services and pathways for older people with complex health and social care needs to enables a shift in the delivery of care from the acute hospitals towards community based planned coordinated care. The objective of the National Integrated Care programme for Older People (NICPOP) is to improve the quality of life for older people by providing access to integrated care and support that planned around their needs and choices, enabling them to live well in their own homes and communities (HSE, 2017). 

The integrated older person’s service is a specialist multidisciplinary service primarily targeting and managing the complex care needs of the older person with multiple co-morbidities across a continuum of care. The overall aims of the service are to: 

• Provide a specialist geriatric opinion using a multidisciplinary approach to support older people with complex care needs. 

• Develop a person-centred care planning approach that supports robust and timely communication across care settings. 

• Support appropriate and timely reduction of Emergency Department (ED) attendance through the development of care pathways that support GPs and others in assessment of older people with escalating care needs.  

• Provide support and education to the older person, carers and healthcare professionals 

The   Operational Team Lead Integrated Programme Care Older Persons role is multifaceted: 

• The post holder is responsible for the day-to-day operational management of the Integrated Care Team (Older People) and HUB functions.
• The post holder will develop an Operational Policy that captures the functions of the hub and the MDT roles and functions. The Operational Policy will act as a key reference point, setting out the key functions of the Hub and specialist OP MDT.    

• The post holder will operationally manage all of the staff in the Hub. Professional Reporting for all disciplines will continue with the relevant HOD/ DPHN / or other as appropriate. This will be reflected in a management matrix to be signed off locally, which will set out the basis of the working relationship between local Heads of Discipline and the Team Co-ordinator. 

• The post holder will support the development of dynamic linkages between the Ambulatory Care Hub (HUB), the Community Healthcare Networks (CHNs) and the acute hospital, to address the needs of the population of older people living with frailty in a CHN as per the National Integrated Care Programme for Older Person (NICPOP) model. 

• The post holder will ensure that team structures are attended to in order to ensure that the service is consistent with recognized best practice in team functioning. This includes MDT clinical reviews and team operational meetings. 

• The post holder will play a pivotal role in collaborating with the Community Healthcare Network Manager and the ICPCD Team Co-Ordinator to adopt a population based approach to services, completing a population stratification and identifying those clients most at risk, for management within the CHN and Specialist Teams 

• The post holder will work with Community Healthcare Network (CHN) colleagues including wider health and social care providers (primary and social care, community and voluntary organisations, local authority to support older people to live well at home  

• The post holder will establish a proactive approach to caseload management to ensure team capacity and flow is maintained. This will for example will include a database of at risk individuals and or/by creating a virtual hub approach.   

• The post holder will work with the Consultant Leads /Project MDT and existing outreach /in reach services to develop integrated criteria for referral and on- going support ensuring a seamless continuum of care for the patient. 

• The post holder will ensure that all services are operating optimally and timely care is being provided to all Older Persons accessing the healthcare professionals at all levels of the service. 

• The post holder will develop and operationalise care pathways as per the service model in tandem with clinical lead and CHN leads (network manager and GP lead). This will address key pathways as a priority (Falls, Memory, Dementia) to ensure that vulnerable older persons clinical needs (acute or chronic) are assessed promptly in the ambulatory care / community setting (integrated approach with the acute hospital as required) and that they are supported in accessing the appropriate care pathway in a timely manner.  

• The post holder will ensure older persons are facilitated to understand their care needs and to work in partnership with the Multidisciplinary Team (MDT) and wider community to ensure the provision of care in an ambulatory model and at home when possible.  

• While clinical functions are desirable to the role of the operational team lead integrated care for older persons, the priority functions he/she performs is coordination of team and hub operations ensuring the provision of a seamless integrated service with a multidimensional and multidisciplinary input for the older person across the care continuum. 

Professional Qualifications, Experience, etc.

Candidates must have at the latest date of application:

• A significant record of accomplishment in leading and implementing service improvement within a health system.

• Have substantial experience, ideally in the speciality area (Older Persons Services)

• Demonstrate evidence of continuing professional development at the appropriate level.

• Experience of interacting with multiple internal and external stakeholders as relevant to the role.

• Have the requisite clinical, managerial and administrative knowledge and ability (including a high standard of suitability and management ability) for the proper discharge of the responsibilities and duties of this role.

Health

A candidate for and any person holding the office must be fully competent and capable of undertaking the duties attached to the office and be in a state of health such as would indicate a reasonable prospect of ability to render regular and efficient service.

Character

Each candidate for and any person holding the office must be of good character.

Related attachements: Operational Team Lead - Grade VIII Integrated Care Programme Older Persons

The HSE Dublin and North East are an equal opportunities employer.