Background:
Paediatric Primary Care Services in Ireland tend to operate in unidisciplinary manner, with different referral pathways, triaging systems, ICT systems and waiting lists, leading to uncoordinated care and multiple waiting lists with assessments at different times. There has been a significant increase in referrals to Primary Care, with increased demand, and recognition of children with support needs from multiple health professionals. Typically, General Paediatric medicine clinics are operated within the Acute Hospital setting, with little direct contact with Primary Care apart from referral letters.

Approach:
Through Sláintecare Innovation and Integration Funding (SIIF), a pilot paediatric multidisciplinary ‘Linn Team’ was developed within a Community Health Network (CHN), serving 13,000 children and young people in West Galway City, Ireland. Linn team consists of two Psychologists, an Occupational Therapist (OT), a Speech and Language Therapist (SLT), a Social Worker, a General Paediatrician, a candidate paediatric Advanced Nurse Practitioner (cANP) with one Administrative Support Officer.
Key community and hospital stakeholders were engaged, including community Primary Care disciplines, Nurses, Community Medical Doctors, GP’s and Paediatricians. Feedback from service users was combined with input from clinicians to identify key challenges.
The focus of The Linn Team is to offer a co-ordinated team approach for children, and young people, who need more than two primary care services including paediatric medicine, and who would benefit from a collaborative "wrap around" approach.
A Primary Care based General Paediatric Clinic was established. Multidisciplinary caseload was collated. A monthly Drop-in MDT clinic provides assessment and pathway identification for children. A joint Paediatrician-Dietician clinic provides collaborative assessment and treatment. An Occupational Therapist and Paediatrician pathway allows for timely diagnosis of Developmental Co-ordination Disorder (DCD) and therapy post diagnosis. An Autism assessment pathway within the network is evolving, supported by increased training/staff supervision. This enabled Primary Care clinicians to collaborate and support families through the diagnostic journey with appropriate autism and child specific aftercare.

Results:
The Linn Team has managed children with both medical and social complexity in Primary Care, avoiding ED presentations and admissions. Early discharge from hospital was supported with rapid follow-up in community clinic. General Paediatric Clinics have offered over 450 new appointments. Waiting times for paediatrician review reduced from 17 months (pre-pilot) to 3months (current). There has been reduction in waiting times for access to Psychology, SLT, OT and Dietetics. 17 multidisciplinary autism diagnostic assessments have been completed, 11 underway. Social Work support within primary care has bridged the gaps between agencies.

Impact:
Formal feedback from children, young people and their families shows high acceptability. Families value knowing who their “team” is, and not repeating their stories multiple times. They appreciate coordinated appointments and timely access to assessment and treatment plans. Interdisciplinary collaboration increased between Primary Care and Acute Hospital services.

Implications:
Each Community Health Network has a unique population and geography. There remains considerable challenges including ICT and information sharing between the community, GP and hospital systems. There is scope and benefit for integrated paediatric interdisciplinary teams like the Linn Team to be expanded nationally.

This paper outlines the process of new forms of collaboration, associated with integrated care systems introduced in England in 2022. Lessons learned from a novel approach to anchor institutes, being positioned in higher education institutions, to form distinctive partnerships across local, national, regional and international collaborators forms the basis of impact evidence reported here as 'ripples in the pond'.
Using critical social science, participatory approaches and collaborative inquiry has been useful theoretical and pragmatic methodologies, from which to explore 'true' collaboration.
Our findings suggest that facilitating effective partnerships, across complex systems is a dynamic process that brings tensions, challenges and opportunities. We outline examples of each, and argue how infinite change and structural inequalities can impeded innovation uptake, whilst creative methodologies blended with critical social science have forged new alliances, that are shaping the future of health and social care systems and architecture.
Implications arising from our work to date identify the need for closer alliances and collaborative arrangements are still needed, to encourage embeddedness, where innovation update can be scaled with sensitivity, suitable for the communities they serve. Importantly, the workforce plays a significant core role in transformation, as both knowledge wealth creators, but also as knowledge wealth mobilisers. Influencing and shaping service models, fit for purpose, within the contexts within which people live and work together. For successful sustainable change to cascade further, the workforce remain central to any transformative process to be reimagined. We conclude with a horizon scan as to what and how improved population outcomes can be realised, in the face of climate change and manmade disasters looming ahead.

Background
The Integrated Care Programme for the Prevention and Management of Chronic Disease in Ireland describes an integrated service across community and acute hospital for patients with COPD/asthma, cardiovascular disease and/or diabetes. Thirty CD CST have been established to provide timely and equitable access to specialist multidisciplinary care at the lowest appropriate level of complexity, in line with Sláintecare, Ireland’s national health policy.


Approach
A quality improvement project was conducted over 6 months with four integrated clinical cardiology sites (CD-CSTs and acute services) to optimise their referral management, triage processes and use of digital technology to deliver a more person-centred service, to improve waiting times for scheduled care and to improve collaboration across General Practice, community and acute services.
Aims of the project were to:
1. Demonstrate a reduction in the number of individuals waiting 12 months or longer for their first outpatient appointment
2. Develop a process by which acute hospitals could identify and refer individuals who were on an outpatient waiting list to the CD-CST where clinically appropriate to support more timely access to care
3. Establish direct GP access services to the CD-CST to support the delivery of the right care, in the right place, at the right time
4. Support the more efficient use of resources

Results
Significant reductions in numbers of patients waiting 12 months or more for specialist input were observed across the four sites, in addition to significant reduction in the wait times for patients to be seen. DNA rates reduced in all sites to <4%. This project has also developed:
• New referral practices which provide transparency in how to navigate the system for GPs & patients.
• Improved collaboration, co-ordination and knowledge sharing across general practice, CD CST and acute teams to deliver person-centred care
• Structured scheduling to manage DNA rates and optimise use of existing resources

Significant GP Engagement as part of the project has created provided positive patient feedback with regard to the services

Implications
The learning and processes developed from this quality improvement project will be shared across all GPs, CD CSTs and acute hospitals to further progress implementation of end to end integrated cardiology services in line with our MoC in Ireland .These processes can also be replicated across the other specialties respiratory and diabetes. This project has demonstrated the impact of the integrated services on OPD waitlists and wait times but also the importance of collaboration to drive delivery of an integrated service to improve patient outcomes.

Maintaining an up-to-date nursing team according to European Society of Cardiology (ESC) guidelines is essential for integrated and high-quality cardiovascular care. Nurses play a crucial role in managing complex conditions, and by following the latest ESC recommendations, they can enhance patient-centered care and improve health outcomes (1). However, barriers such as limited leadership, workload, and resource shortages often prevent the effective use of prevention guidelines, as only 12% of nurses reported implementing them in practice (2). To overcome these challenges, educational and organizational strategies that build nurse self-efficacy and empower them to advocate for evidence-based care are necessary (3).
One successful initiative is the Cardiovascular Nursing Manual (4), a free digital resource validated by the Portuguese Society of Cardiology and the Portuguese Order of Nurses. This manual, which incorporates ESC guidelines, assists in clinical decision-making and provides educational tools for cardiovascular care. It features interactive content covering cardiovascular risk factors, coronary syndrome, heart failure, structural heart disease, arrhythmias, cardiac surgery, and cardiac rehabilitation. Alongside recent ESC recommendations, it provides useful tools for educating cardiovascular patients and standardizing nursing intervention documentation. This cardiovascular nursing manual is being used as a reference for training teams involved in the Cardiac Integrated Care project.
While the free dissemination of this resource might introduce bias into our study, withholding it from Portuguese nurses would be unethical. Hence, alongside the Cardiac Integrated Care project, scientific conferences by the Portuguese Society of Cardiology, Order of Nurses, and the Portuguese Society of Health Literacy are planned to disseminate this manual. The dissemination of this resource through the UC Scientific Repository has been significant since its release in February 2024, with 742 downloads already recorded, demonstrating its wide accessibility and impact.
This approach highlights the critical role of accessible, evidence-based resources in advancing cardiovascular nursing practice and promoting integrated care throughout Portugal.
1. Ski C, Cartledge S, Foldager D, Thompson D, Fredericks S, Ekman I, et al. Integrated care in cardiovascular disease: a statement of the Association of Cardiovascular Nursing and Allied Professions of the European Society of Cardiology. Eur J Cardiovasc Nurs. 2023;zvad009. https://doi.org/10.1093/eurjcn/zvad009.
2. McKee G, Kerins M, Hamilton G, Hansen T, Hendriks J, Kletsiou E, et al. Barriers to ESC guideline implementation: results of a survey from the European Council on Cardiovascular Nursing and Allied Professions (CCNAP). Eur J Cardiovasc Nurs. 2017;16(8):678–86.
3. Deaton C. Implementing clinical practice guidelines: a responsibility for nurses and allied health professionals? Eur J Cardiovasc Nurs. 2012;11(3):263–4.
4. Homem F, Caetano A, Reveles A, Martins H, Sousa J, Rodrigues L, et al. Manual de Apoio à Consulta de Enfermagem ao Utente com Patologia Cardiovascular. 2023. https://estudogeral.uc.pt/handle/10316/107474