出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction: Approximately 1 million people in Ireland today are living with Diabetes, Asthma, COPD or Cardiovascular disease. This is projected to increase by 4% annually. This represents a major challenge for the health services, society and the economy. To meet these challenges the HSE’s Clinical Strategy and Programme Health and Well-being team have designed and supported the implementation of models of Integrated Care (IC) for management of people with each of these chronic diseases. Practice change implemented : Since 2015, 61 chronic disease IC posts have been secured through the programme to support the transfer of care from secondary to primary care for people with a chronic illness. These include innovative IC nurse specialists for each of the chronic diseases based in the community and serving clusters of General Practices linking them to the local specialist services. They also include community podiatrists to implement the integrated diabetes foot care model, dietitians and physiotherapists to ensure accessible local structured education in diabetes and pulmonary rehabilitation. This represents a significant change in practice for care providers. Aim and theory of change : The aim of the programme management function was the co-ordination and facilitation of this change. In the initial phase the Programme Managers spent time developing a strategy to help ensure successful implementation of these posts. Each of the stakeholders involved were identified. Roles and responsibilities in the implementation process were agreed with the relevant Divisions. The main resistor identified was the difficulty in overcoming the challenge posed by people‘s reluctance to change. The Programme Managers recognised that in order for the changes to be realised, the vision for these posts needed to be communicated. Meetings with all clinical disciplines and management were held, the benefits of the change for each of these groups were framed to inspire and motivate them to support the implementation. The Programme Managers ensured an inclusive approach was taken as the success of the project is dependent on collaboration amongst multiple individuals and groups to achieve its goal. Targeted population and stakeholders : People with chronic illness Advocacy groups Healthcare providers Healthcare Management Timeline : This project has been ongoing since 2015. All 61 chronic disease posts will be in place by March 2017. Highlights (innovation, Impact and outcomes) Innovation: Co-design of integrated services across Clinical Programmes, National Directorates, service providers and functions Development of new governance structures for the implementation of chronic disease IC services New documentation developed e.g. job descriptions, Terms of References, reporting structure models. Impact: Reinforced the need for IC services for chronic disease Presented opportunities for engagement and knowledge sharing between stakeholders from different parts of the system where previously there was limited overlap Introduced new ways of working for Programme Managers Enhanced knowledge of the potential barriers to service integration including infrastructural challenges e.g. IT, communications, physical space, equipment. Demonstrated the importance of the National Clinical Advisor & Group Lead role in providing leadership for a co-ordinated approach to chronic disease management across these 4 diseases Outcome: Key performance indicators are currently in development which once evaluated will assist in demonstrating the effects of these posts on services Sustainability : Participation of multiple stakeholders and the shared learning gained will contribute to success. Project aligned to Government policy for IC. Transferability : Approach and learning on the design and implementation can be transferred to future initiatives by the IC Programme (ICP) for the Prevention and Management of Chronic Disease, and other ICPs. Conclusion & Discussion : Effective Programme Management is an essential element to supporting Implementation of IC. Lessons learned : Importance of an inclusive, collaborative team based leadership approach in introducing system wide change.
关键词：chronic disease ; programme management ; design ; support
