Making integrated care a reality: implementing at scale an integrated model of care for the prevention management of chronic disease in Ireland

Background: Due to an ageing population, the prevalence of chronic disease (CD) multimorbidity is rising in Ireland and internationally. In Ireland, CD care was traditionally characterised by siloed, reactive care, culminating in repeated hospital admissions. This was neither patient-centred nor sustainable. Health services needed to evolve to meet changing population need. Approach: The Integrated Model of Care for the Prevention Management of CD (MoC) takes an evidence-based population health approach to the prevention management of four major CDs: type 2 diabetes; asthma; COPD; cardiovascular disease. A key focus of the MoC is to shift care out of the hospitals, into the community through driving a preventive and proactive approach to CD and associated complications. A new layer of specialist multidisciplinary care has been established in the community to provide timely equitable access to specialist advice to support the GP in providing holistic, person-centred care for patients living with more complex CD and multimorbidity as close to home as possible.This MoC draws on Ireland national health strategy Sl intecare best international practice and evidence, with extensive input from healthcare professionals across the acute, community, voluntary sectors and patient representatives. Results: Over 50million in funding was secured in 202 to implement this MoC across the country. The Integrated Care Programme for the Prevention Management of CD has led out on the implementation of this significant health service transformation at scale. Early evaluation indicates that the MoC is impacting positively on patient outcomes. For example: 9% of individuals who are enrolled in the Structured CD Management Programme in General Practice are now fully managed in primary care i.e the shift of the majority of CD care to the community is demonstrated. There has been a 6% reduction in hospital discharge episodes for individuals with one or more of the four major CDs listed above in 2023 compared to 209 (compared to a less favourable 3.5% reduction in all medical admissions) There has been a 24% reduction in 30- and 90-day readmission rates per 00,000 of the population for the chronic conditions covered as part of the MoC There has been a 65% reduction in the number of people waiting over 2 months for first outpatient review in 7 hospitals due to the integrated care pathways now available across hospital and community Implications: Implementation of the MoC is transforming the delivery of CD care in Ireland. However, there are sites that have been resistant to change, raising issues of inequity for CD care in some regions of the country. The ICPCD is leading a change management approach across all sites to support the implementation and embedding of the MoC. We seek to share our insights on our continuing journey to full implementation with conference attendees.