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The aim of this study was to co-create a definition and generic descriptors for person-centred coordinated care for Ireland generated from service users’ narratives. An overarching action research approach was used to engage and empower people to tangibly impact health policy and practice. Through focus groups and a qualitative survey, primary data were collected from a national sample of health services users, caregivers and health care service users’ representative groups. Thematic analysis was used to analyse the data. Three major themes were co-produced as essential care elements. These were: ‘My experience of healthcare’, ‘Care that I am confident in’ and ‘My journey through healthcare’. Through an IPPOSI partner project steering group and their membership groups’ contribution, these themes were further refined into a definition of person-centred coordinated care and nineteen related generic descriptors. Key findings demonstrate that within complex, fragmented healthcare systems, the subjective expectations of service users should be integrated into care delivery, with a scaffolding of services to meet service users’ needs between care settings and disciplines and over time.

Introduction: Reorganisation of healthcare services into clinical networks has emerged in recent years as a mechanism to improve patient outcomes. In 2014, an International Working Group Report recommended the cessation of surgery in Northern Ireland (NI) for children with Congenital Heart Disease (CHD). This resulted in children from NI travelling to Great Britain (GB) to receive life-saving surgical intervention, a significant risk to the child and at great cost to the health services and families. The group made a number of recommendations that included the creation of an All-Island CHD Network to enable the CHD services in NI and Republic of Ireland (ROI) collaborate with each other and work as a single Network to achieve essential national and international standards for CHD service provision. Objectives: To develop an All-Island Congenital Heart Disease (CHD) Network to provide high quality and timely access to specialist cardiac services for all children and young people on the island of Ireland. The core objectives of the All-Island Congenital Heart Disease (CHD) Network are: a) Appropriate CHD treatment for all children and young people on the island of Ireland as close to home as deemed appropriate. b) Timely access to quality treatment through the creation of a single waitlist that is aligned to international wait times. c) Provision of a safe and sustainable model that serves the needs of children and families into the future. d) Development of a research and innovation hub that delivers best practice solutions utilising a unique genotype on an all-island approach. Methods: A framework for an all island clinical network for congenital heart disease was developed to manage the all-island service delivery model. This built on existing services and drew them together in a network of care which is service user focused and locally responsive. The basic concepts of the network are of partnership, service integration and formal arrangements. The network consists of linked groups of health professionals and organisations from primary, secondary and tertiary care, working in a co-ordinated manner, to ensure equitable provision of high quality, clinically effective services. Results: To date, all NI Cardiac Catheterisations are carried out in ROI. In addition, all NI emergency and urgent surgical cases have been transferred to ROI, thereby eliminating the need for children and families to travel to Great Britain to have their surgery performed which resulted in a negative experience for families. During 2018, it is planned to commence the transfer of elective surgical patients to the ROI waiting list, with the plan that there will be an all-island surgical waiting list in 2019. The Network model of care includes the development of services in regional centres, implementation of an all island CHD research strategy and the development of a joint training and education programme for health care professionals. Conclusions: The all-island CHD Network is a linked group of health professionals and organisations from primary, secondary and tertiary care, working in a co-ordinated manner, to ensure equitable provision of high quality, clinically effective services to this complex cohort of patients

Introduction: Socially excluded individuals have higher morbidity and mortality, use a disproportionate amount of healthcare resources and generate a large volume of potentially preventable healthcare and other costs compared to more privileged individuals. Through a person-centred, whole-system and multi-disciplinary approach to care delivery, integrated care improves care for people with complex needs who are likely to have poor outcomes. Homeless and other socially excluded individuals frequently need the input of multiple health and social care providers. The rehabilitation needs of these individuals have not been explored previously and this projects aim was to establish a baseline of need for this cohort. Design, subjects and setting: A prospective cohort study of cases presenting for discussion at an inclusion health multidisciplinary team meeting in an urban homeless service. Methods: All cases discussed at the inclusion health MDT were studied to identify demographics, inclusion health and rehabilitative needs over a 4 month period. Results: 97 cases were studied over the 4-month period. 66 (68%) were male and 31 (32%) were female. 15 (15%) were over 60 and 82 (85%) were under 60 (age range 18-80). The inclusion health needs of this population are diverse and complex. 50% of cases discussed were considered to have rehabilitation needs. 37% had a physical impairment the most common causes of which were fractures and chronic leg ulcers mainly in intravenous drug users and chronic alcoholics. 42% were considered to have a cognitive impairment. The aetiology of cognitive impairment was uncertain due to significant comorbidity and increased prevalence of mental health conditions. A history of learning disability was proposed in a number of cases. 20% of cases had both physical and cognitive impairments. 76% of individuals were currently addicted to alcohol or drugs. 63% had mental health needs including severe and enduring mental illnesses, and 71% had a chronic medical condition. Discussion: The inclusion health needs of this population are diverse and complex. A traditional rehabilitation programme would not suit the chaotic lifestyles of these individuals and often access requires a fixed address which none of these individuals have. Conclusion: The results of this study show that the rehabilitative needs of this cohort are significant and are not being met through traditional rehabilitation medicine models of care. Limitations: A detailed analysis of the specifics of the rehabilitative needs was not possible at this stage of the project and efforts are underway to identify a biopsychosocial needs assessment tool that can identify all the needs of individuals. We were also not able to assess if individuals had access to community based general rehabilitation services but it was the view of the MDT that a traditional rehabilitation programme would not suit the chaotic lifestyles of these individuals. Suggestions for future research: Development of innovative ways to assess and provide appropriate services to these individuals.

Introduction: Co-design has been identified as a participatory method to create person-centred integrated healthcare services that align with older people’s values and lived experiences. Description: Existing guidelines on conducting co-design primarily focus on in-person methods with limited guidance on using digital methods to collect data. This gap in knowledge is particularly pertinent when co-designing with older people who can experience challenges with digital literacy and accessibility. This article uses the exemplar of a pilot site within a European co-design research project, aiming to create digital health technology to support integrated care, to describe the steps and considerations required when collaborating with older people in an online environment. Focus groups and one-to-one interviews were conducted utilising digital mediums of teleconferencing and telephone calls to engage and collaborate with older people. Discussion: Several preparatory steps are required to effectively bridge the digital divide and conduct co-design with older people including engaging gatekeepers, relationship and trust-building, assessing digital literacy levels, education and providing technological support. Conclusion: This article highlights the steps and considerations that researchers should be aware of when embarking on co-designing with older people in a digital setting. The authors describe their methods that promotes inclusivity and the empowerment of older people as equal collaborators in the research process. The co-design approach and recommendations can be applied to various research settings and wider areas of integrated care with this population.

Introduction: An in-depth understanding of patient perspectives contributes to high-quality, value-based health care. The aim of this study was to explore the values, needs, and preferences of stroke patients across the continuum of care. Methods: We performed a qualitative study, as part of the larger ValueCare study, involving 36 patients who have had ischemic stroke within the past 18 months at the time of recruitment. Data were collected between December 2020 and April 2021 via one-to-one telephone interviews. All interviews were audio-taped and transcribed verbatim. The interview data were analysed using a thematic approach. Results: The analysis resulted in five themes: (1) patients’ values about health care, (2) information and education, (3) psychological support, (4) follow-up care, and (5) continuity and coordination of care. Patients valued a compassionate professional who is responsive to their needs. Furthermore, patients indicated a need for tailored health information, psychosocial services, pro-active follow-up care and improved coordination of care. Discussion and conclusion: Stroke patients emphasised the need for tailored information, psychological support, pro-active follow-up, and improved coordination of care. It is advocated for professionals to use a value-based care approach in order to satisfy the individual needs of patients with regard to information, communication, and follow-up care.

Background: In Ireland, as in many healthcare systems, health policy has committed to delivering an integrated model of care to address the increasing burden of chronic disease. Integrated care is an approach to healthcare systems delivery that aims to minimise fragmentation of patient services and improve care continuity. To this end, how best to integrate primary and secondary care is a challenge. This paper aims to undertake a scoping review of empirical work on the integration of primary and secondary care in relation to chronic disease management. Methods: A search was conducted of ‘PubMed’, ‘Cochrane Library’ and ‘Google Scholar’ for papers published between 2009–2019 using Arksey and O’Malley’s framework for conducing scoping reviews. Results: Twenty-two studies were included. These reported research from a wide range of healthcare systems (most commonly UK, Australia, the Netherlands), adopted a range of methodologies (most commonly randomised/non-randomised controlled trials, case studies, qualitative studies) and among patients with a range of chronic conditions (most commonly diabetes, COPD, Parkinson’s disease). No studies reported on interventions to address the needs of whole populations. Interventions to enhance integration included multidisciplinary teams, education of healthcare professionals, and e-health interventions. Among the effectiveness measures reported were improved disease specific outcomes, and cost effectiveness. Conclusion: With healthcare systems increasingly recognising that integrated approaches to patient care can enhance chronic disease management, considerable literature now informs how this can be done. However, most of the research published has focussed on specific diseases and their clinical outcomes. Future research should focus on how such approaches may improve health outcomes for populations as a whole.

The first Irish National Audit of stroke care by the Irish Heart Foundation (IHF) in 2008 found only one hospital had an acute stroke unit, less than 1% stroke patients got thrombolysis and death from stroke was 19%. The Irish National Stroke Programme (NSP) was set up in 2010 to modernise stroke care in the country and reduce by one the death and disability from stroke each day, through the implementation of international guidelines for management of stroke. The programme appointed joint neurology and geriatric medicine clinical leads, a senior public health doctor and senior stroke nurse as programme manager.NSP produced a Model of Care identifying five key areas for development: Prevention; Emergency Stroke Care; Acute Stroke Unit Care; Community Stroke Care and a stroke register. The NSP established the National Stroke Register (NSR) ,an essential tool to measure effect of implementation of the Model of Care;providing data for planning and resource requirements for individual &national stroke services, evaluation and clinical audits..The programme identified three national KPIs 1) 90% of acute stroke patients admitted to a stroke unit; 2) stroke patients to spend 90% of LOS in a stroke unit;3) a national thrombolysis rate of 12%. The KPIs were agreed nationally by Health service Executive and circulated to all hospital managers. The Stroke Programme identified clinical leads and supported a gap analysis in each acute hospital regarding acute stroke unit care and ability to deliver 24/7delivery of thrombolysis. Through this process key staff vacancies were prioritised and innovative solutions to 24/7 senior assessment ,like telemedicine piloted and supported In 2015 the second Irish National Audit on stroke confirmed the significant progress of the stroke programme whereby 21/27 acute hospitals now had an acute stroke unit and there was better processes of stroke care (Table 1 & 3). The national stroke register also showed significant improvement in KPIs where currently 69.2% of patients are admitted to an acute stroke unit and 11.8 % of patients received intravenous thrombolysis (Table 2). Both the independent IHF audit and national stroke audit also identified ongoing clinical challenges around care of swallow and mood assessment following stroke. The National Stroke Programme has now embarked on writing a funded pragmatic 5 year strategy to ‘make big stroke history’ with a focus on embedding recent high impact medical advances in the key areas of our stroke services ‘acute care and cure’, ‘Prevention’ , ‘restoration to living’ and ‘research and education.’ Table 1 : Irish Heart Foundation Stroke Audits IHF National Stroke Audit 2008 IHF National Stroke Audit 2015 Mortality 19% 14% Stroke Units 1% 85% CT Scanning 24/7 84% 100% Clinlead for Stroke 32% 85% Nurse Specialist 14% 85% Table 2: National stroke Register & KPIs National KPI s for stroke 2013 NSR 2017 NSR 1. Admission to stroke unit 64.1% 69.2% 2. >90% of LOS in stroke unit 57.2% 70.4% 3.Thrombolysis 11.3 11.8% Table 3 Processes of care in natiobnal stroke audits and regsiter Stroke Audit 2008 Stroke Audit 2015 NSR 2017 Swallow Screening 26% 29% 66% Mood Assessment 28% 33% 33% Aspirin within 48hrs 49%* 70% 76%