How Integrated is Our Integrated Care? Exploring Concepts and Contexts in the Care for Older Persons During Discharge in Ireland


Background

Across Ireland, older people often experience fragmented care when discharged from hospital to home or community settings. Although integrated care aims to ensure a smooth, coordinated transition, its implementation frequently falls short of expectations. The consequences include delayed discharges, hospital overcrowding, and adverse outcomes such as medication errors and readmissions. As the population ages and multimorbidity rises, the need for well-coordinated, person-centred discharge planning has become more urgent.

Approach

This paper provides a critical discussion of integrated care within the Irish context, particularly as it relates to the discharge process for older persons. Drawing on national and international literature, as well as policy frameworks such as Sláintecare and the Integrated Care Programme for Older Persons (ICPOP), the discussion explores the conceptual underpinnings of integrated care and how it operates in practice. The paper analyses the roles of key stakeholders—including nurses, patients, families, and multidisciplinary teams—and examines systemic and contextual barriers that limit effective care integration. It also reflects on opportunities for innovation, particularly the use of digital health technologies and nurse-led interventions.

Results

The discussion highlights that, despite strong policy frameworks, integrated care remains inconsistently applied across Irish healthcare settings. Persistent barriers include limited communication between hospital and community services, inadequate staffing, and underdeveloped digital health systems. Nurses, who play a pivotal role in facilitating discharge and continuity of care, often navigate complex systems without adequate support or resources. Nonetheless, examples of good practice exist—nurse-led discharge planning, collaborative team approaches, and the adoption of electronic health records have been shown to enhance patient satisfaction, reduce readmissions, and improve communication between providers. These examples illustrate that integrated care can be achieved when supported by clear protocols, interdisciplinary collaboration, and active patient and family engagement.

Implications

For practice, the paper emphasizes the need to strengthen the role of nurses as coordinators of care transitions, supported by adequate training and resources. Policymakers should prioritize investment in community-based services and digital health infrastructure to facilitate information sharing and improve care continuity. Nursing education should integrate concepts of care coordination, interdisciplinary teamwork, and person-centred discharge planning into curricula.
For research, further exploration is needed on the impact of nurse-led discharge interventions and technology-enabled integration on patient outcomes and system efficiency.
For international delegates, Ireland’s experience underscores a universal challenge—bridging the gap between the theory and reality of integrated care. The Irish context offers transferable insights into achieving sustainable, person-centred systems where interdisciplinary collaboration, digital transformation, and community capacity-building can collectively improve outcomes for older persons globally.

References available

Background
Within the framework of the Transformational Project for Care Integration, funded by the Catalan Health System, implemented across five regions (Osona, Alt Maresme, Selva Marítima, Alt Empordà, and Baix Empordà), we present the outcomes of implementing Clinical Practice Communities (CPCs) as a collaborative tool among healthcare professionals. The project’s main goal is to establish an integrated care model for complex patients aged 80 and above.
The rise in multimorbidity and clinical complexity among older adults leads to reduced quality of life and increased healthcare utilization and costs. To address this, the Catalan Health Service has promoted the Complexity Care Pathway as a framework to enhance coordination across care levels. This pathway has been adapted to the organizational realities of each territory.
Due to the challenges in evaluating its implementation, CPCs have emerged as a key mechanism for shared monitoring among stakeholders, supporting a harmonized and context-sensitive rollout. The overarching aim is to advance toward integrated, person-centered care tailored to each region.
Approach
The project is structured around the design, implementation, and evaluation of an effective integrated care model, with two main components:
• Creation of CPCs: Collaborative workspaces for shared learning among professionals from different sectors and organizations, aimed at identifying common challenges and co-designing adapted solutions.
• Development of a technological platform: a support tool that facilitates resource selection, patient follow-up along the defined pathway, and identification of the reference professional.
Results
Key actions included:
• Definition and structure: setting objectives, activities, and links with existing territorial structures. Each CPC includes representation from all entities and care lines, and a Promoting Group (5–7 members) with defined roles, coordination functions, and self-assessment criteria to ensure operational continuity.
• Institutional engagement: Agreements between entities with clearly defined responsibilities.
• Communication and awareness: Sessions with professionals and managers to ensure shared understanding.
• Territorial adaptation: CPCs are configured according to the characteristics, resources, and organization of each region, avoiding imposed professional profiles. Despite local adaptations, primary care, emergency, and intermediate care professionals are always consistently involved.
• Initial training: sessions to equip Promoting Groups with collaborative tools and management and evaluation strategies, supported by accessible and updatable documentation.
• Formalization: Four CPCs have been established, each with 15 to 23 members depending on the region’s size. CPC activities include territorial information review, clinical case analysis (successes and challenges), identification of training needs as drivers of change, critical review of scientific evidence and trends, and peer support to foster competency development.
Conclusion
CPCs have become a key instrument for the territorial implementation of the Complexity Care Pathway. They have fostered interprofessional collaboration, enabled the validation and adjustment of theoretical care circuits to real-world practice through case reviews, and supported data-driven territorial monitoring.

Seven chronic disease modernised care pathways (MCPs) were funded for national implementation in Ireland in 2023. The MCPs set out how scheduled care may be delivered closer to home, in a more effective and efficient manner, shaped to meet the clinical need of the individual referred.
Against the backdrop of varying levels of progress in implementing the MCPs across Ireland, and increased demand for scheduled care services, a joint initiative between the Integrated Care Programme for the Prevention and Management of Chronic Disease (ICPCD) and two regional integrated care teams was developed with the aim of enhancing integrated working across the acute and community cardiology services.
Local Cardiology Integrated Care Working Groups were established at each site comprising frontline clinicians and senior decision makers from acute hospital and aligned community specialist teams. A National Scheduled Care Working Group was established to provide strategic guidance and support the local teams to implement locally agreed solutions.
The local groups agreed a shared vision and consulted with GPs and service users to map out the patient journey to identify priorities for action. Solutions were developed using PDSA cycles at each site, with progress reviewed and processes refined at the weekly meetings.
This initiative demonstrated the positive impact of the full implementation of the MCPs on delivering a more timely, responsive scheduled care service. Over 30% of GP referrals to the hospital outpatient service can be dealt with by the community specialist teams. Over 50% of referrals into community specialist teams can be managed through virtual means. Service users value the more responsive approach to care through virtual and in-person offerings.
The establishment of the local working groups involving senior decision-makers across acute and community was an important enabler in building relationships and networks to drive change and the delivery of an integrated, person-centred scheduled care service. Collective changes in practice across acute and community team members enabled delivery of a more efficient, effective and responsive service with reduced waiting times achieved across both sites.
This initiative has highlighted the benefits of harnessing technology and the delivery of the MCPs by the community specialist teams to reduce waiting times for scheduled care. More importantly, it has demonstrated the benefits of improved collaboration across acute and community at the local level to shape the scheduled care services to better meet patient need.
Systems leadership where all team members collaborated across healthcare environments and disciplines to achieve common goals enabled a focus on delivering a person-centred service, as opposed to a focus on delivering a service within traditional boundaries . The pooling of resources, data and expertise, underpinned by PDSA cycles and co-design of solutions delivered a more agile and responsive service. The national role was one of enablement and this has been identified as an important factor in supporting a culture of integrated working within the health and social care services

Through this unique health system partnership between the West Toronto Ontario Health team and LAMP CHC, iHelp Centres were established within Toronto Community Housing buildings in Toronto, Ontario – at the core of this model, the existence of community health workers have supported creating 1:1 personalized care plans, multilingual support and social connectedness.
While our presentation last year focused on our operations and tenant engagement, this year we chose to highlight our unique partnership with a community health center in West Toronto and the community health worker model that works to enhance social prescribing and facilitate health navigation. Community Health Workers at iHelp Centres are instrumental in establishing an ongoing presence, building early relationships and becoming a familiar face in an environment where there has been historical mistrust. The expertise of CHWs comes from their daily interaction with the community in identifying tenant needs, concerns and making connections to appropriate services, and reaching people in environments where they are comfortable, through familiar languages and using an anti-oppressive approach. Some examples of CHW led initiatives at our iHelp Centres include
women’s and men’s wellness events, Food markets, social programming and other activities that are reactive to the needs of the community they witness and work with on a day-to-day basis.The effectiveness of a community health worker demonstrate scalable model of integrated care with the capacity to support some of the most complex community care. While the long-term impact on the health of the target populations is still being evaluated, the early outcomes show greater engagement with the Health & Wellness Centres than previous service models, significantly improved collaboration and care coordination between providers, and increased rates of attachment for Toronto Community Housing tenants.
The most notable result to date has been demonstrated through our findings that feelings of safety and social cohesion, which were initially surprisingly low before introducing this service, have continued to increase and grow. This has been demonstrated through early results of a tenant survey, and can anecdotally be attributed to the introduction of familiar faces who provide 1:1 care, create an ongoing presence in both buildings and contribute to the overall environment of a third, welcoming space. A mixed-methods approach has highlighted the value of meaningful stakeholder engagement in delivering services that reflect community needs. When the needs of the community are dynamic, the Community Health Worker roles are the first line for tenants and community members to identify opportunities to respond and adapt. Ongoing monitoring and evaluation efforts are underway to assess both client experience and community impact to ensure the continued effectiveness of the iHelp model. Initial findings have been positive on the impact the iHelp Centres have had.
Participants will gain insights into how co-designed, hyper-local care models can advance health equity by meeting people where they are. Participants also will understand relevant engagement strategies, leveraging the right partnerships, focusing on a person-centred approach in addressing a multitude of health outcomes, and how the Community Health Worker role is central to achieving this.