Kerry Integrated Care

Programme shifts care away from acute hospitals and into the community

Integrated Care and cups of tea are very important at the Kerry Integrated Care Programme for Older Persons (ICPOP) hub in Tralee.

Located in the McAuley unit at Balloonagh, the primary objective of Kerry ICPOP is to develop and implement integrated services and pathways for older people with complex health and social care needs, shifting the delivery of care away from acute hospitals towards communitybased, planned and coordinated care.

Care is provided by a multidisciplinary team (physiotherapy, occupational therapy, speech and language therapy, dietitians, healthcare assistants and specialist nurses) under the clinical governance of a consultant geriatrician. Kerry ICPOP focuses on the clinical areas of frailty, falls and memory/dementia. The team works closely with acute and primary care services to support older people to live well in their own homes for as long as possible.

And they also do a great cup of tea, according to Mairin Cullhane, who became a patient at the hub after a fall at home left her with a broken hip. The ICPOP team supported her to return to her own home as quickly as possible - and far faster than she thought possible.

“It meant everything. I was at home, and I was able to say what I wanted. Life was happier.”

And the tea was plentiful, and made just right, with Mairin declaring, “We were offered it, we didn’t have to ask for it – and it was lovely.”

The team at the hub work together to assess frail older people aged over 70, especially those who are at risk of a fall, and over a six-week period find ways to keep them safe and well at home.

Simple things like a cup of tea and the warm welcome that goes with it make a healthcare appointment that could be stressful for people run smoothly.

From the moment a member of the team picks up the phone or meets someone at the front door, everyone is guaranteed a warm and reassuring welcome.

Situated in a calm spacious environment there’s plenty of space for the multidisciplinary team to carry out their work - a true one-stop shop.

The physiotherapy gym is the location for transfer, mobility and functional assessments and also the prescription of bespoke exercise programmes. Occupational therapist Emma explained how the the therapy kitchen is used to assess activities of daily living – including making the ever important cup of tea!

The use of low tech equipment is often recommended to make life easier and support independent living. Communication and swallowing issues are assessed and some dietary advice can be provided by the experienced team. Patient medication is optimised and diagnostics ordered by the consultant geriatrician and the team of Registrars.

Pat Cullane, Mairin’s husband, describes the key to the team’s success.

“We were made feel important, we were made feel part of the system, everything was explained to us,” he said, adding, “The confidence they instilled in us was great, and we’d recommend it to people. We were apprehensive at the start, but it exceeded all our expectations.” * Referrals to Kerry ICPOP are made through GPs (using Healthlink), consultants at UHK or in old age psychiatry, or the Frailty Intervention Team. Contact 066 718 4910 or Kerry.icpop@hse.ie