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ICP for Prevention and Management of Chronic Disease

The objective of the Integrated Care Programmes is to design an integrated model of care that treats patients at the lowest level of complexity that is safe, timely, efficient and as close to home as possible. The Integrated Care Programme for the Prevention and Management of Chronic Disease (ICPCD) focuses on a number of chronic diseases that impact a large number of health service users.

Approximately 1 million people in Ireland today suffer from Diabetes, Asthma, Chronic Obstructive Pulmonary Disease (COPD) or Cardiovascular disease.The Irish longitudinal study on ageing, TILDA, reports that 64.8% of our over 65 age cohort live with co-morbidity.  This is defined as the presence of two or more chronic conditions.The current and projected impact of chronic disease represents a major challenge not just for the health services, but also for Irish society and the Irish economy.  We have more people living with chronic disease and multiple co-morbidity, they are living longer with the disease, and while it is good that the range of treatments available is increasing and improving, this also comes at a cost. Unless we plan for these changes now, we are going to run into significant difficulties in ten years' time. In fact, we are facing those difficulties already, as we can see in the 5% to 6% increase in the presentations to our emergency departments year on year and the impact that this is having on our acute hospital system and, in particular, available bed capacity for elective work.

The way we currently provide care for these chronic conditions is relatively ineffective, inefficient and ultimately unsustainable. Too many people end up needing hospital admission due to their chronic disease, which is something that these patients would prefer to avoid. Too many people depend on hospital out-patient services for management of their chronic diseases, which results in delays in appointments for all patients and they may experience gaps in their care as services are stretched.

We need a better way of caring for people with these diseases, and we need to do more to prevent them. To progress this, the HSE has established an Integrated Care Programme for the Prevention and Management of Chronic Disease. This programme aims to provide better care to people with chronic diseases. This will be achieved by providing a continuum of preventative, management and support services to patient with these conditions.  This is built on an approach which helps people understand and care for their own condition in collaboration with their General Practitioner and the general practice team. This includes easy access to diagnostics and specialist supports in the community and includes a close co-ordination with hospital services so that people can receive the care they need, when they need it and in the most appropriate way for their circumstances, be it at home, in the community or in hospital.

This will require a significant re-orientation of service delivery and associated resources, and will be challenging, but we believe that it is the best and most sustainable approach.

Integrated care, as set out in Future Health, can be defined as care that improves the quality and outcome for patients and their immediate families and carers by ensuring that;

-       Needs are measured and understood,

-       Services are well coordinated around these assessed needs,

-       It is preventative, enabling, planned and well-coordinated,

-       It is a system of care that looks at the impact on health and wellbeing of the patients concerned.

Clinical Strategy and Programmes Division