Expanding the Caredoc Community Intervention Team by integrating and cooperating with healthcare providers

Abstract

Purpose:To expand and develop the Caredoc integrated community intervention team (CIT) to engage with further stakeholders and to empower healthcare services and workers to support coordination and cooperation for patients, general practitioners, community services and the acute hospital. Objectives: To expand the Caredoc CIT model of care to incorporate hospitals and services in the Southeast of Ireland To inform and describe the model of care to hospitals, GPs and patients To support all stakeholders in moving to a new way of care To ensure all stakeholders are comfortable with the transition To empower all stakeholders by ensuring everyone involved is aware of their role and the role of others To securely integrate patient notes across all stakeholders to ensure continuity of care and safety The Caredoc CIT provides an acute nursing service to patients in their own home, treatment centre or care facility in the community who would traditionally be treated in the hospital setting. The service supports patients, primary care and hospital services by utilising and optimising resources to facilitate early hospital discharge and hospital avoidance. Building capacity: The Caredoc CIT service began in September 2011 after months of engagement between hospital, community and primary care services in the Carlow and Kilkenny areas in the Southeast of Ireland. The service has been delivered successfully over the last World Congress on Integrated Care 2014, Sydney, November 23-26, 2014. International Journal of Integrated Care – Volume 14, 8 December – URN:NBN:NL:UI:10-1-116635– http://www.ijic.org/ number of years and has produced significant benefits to the stakeholder’s involved and cost savings to the health service. Patient surveys have 100% satisfaction ratings with the service. The synergy and enhanced cooperation between services is something the Caredoc CIT team wanted to extend to other areas. The extension began in mid-2013 to Wicklow and is now successfully embedded in the area. The service will now be extended to Waterford, Wexford and South Tipperary. Conclusions: The main objectives were met in the roll out of the CIT model for Wicklow. Throughout the process the key stakeholders were involved from the beginning of the project and encouraged to input to the implementation plan. Individuals were empowered to take responsibility for their assigned role and encouraged to engage with other services providers and personnel. Key lessons learned: Empowering individuals at the initial stages of projects promotes collaboration and cooperation Ensure everyone involved is kept informed of key decisions or any changes Promote the service with patients and stakeholders to ensure no one is excluded The experience gained and all lessons learned are internationally transferrable to other services and organisations.