'It's brilliant coming in here': Older patients feel right at home with integrated healthcare

Giving an example of how the hub could impact hospital numbers, a lead geriatrician said that, for example, supporting an elderly woman to come off unnecessary medication making her drowsy can “significantly
reduce” risks of falling.

This can prevent a hip fracture which would necessitate hospital time.

Indeed, it is clear that something has to happen, as older people last winter bore the brunt of an appalling crisis in hospitals, following the devastating death toll among older people during the pandemic.

On arriving at the Kerry ICPOP, free parking is the first immediate difference in contrast to steep hospital parking costs.

Located in a former Sisters of Mercy convent, the building was adapted including pale green paint for the dementia care corridor as that is linked with calm.

“We are a specialist geriatric service,” said operational team lead Kathleen O’Donoghue.

She estimates they have seen around 2,000 patients with the service ramping up since a move to this building in 2021 following a soft opening in 2020.

That might not sound new but, for a health service historically built on a medical-hospital-first model, under changes as part of the Sláintecare reforms, the shift is taking time.

Geriatrician and clinical lead Richard Liston said research is needed to measure how treating pneumonia cases at home or in nursing homes, instead of in hospital, is affecting hospital numbers. He is hopeful.

Among their treatments is investigating whether a patient’s medication is all necessary, particularly benzodiazepine sedatives.

“They’re on too much anti-blood pressure pills, too much pills for vertigo and all sorts of things,” Dr Liston said, referring to some patients.

“Your heart specialist is not going to look at the rest of your drugs but, at some stage, someone like me has to intervene and look at the totality.”

Part of the hub approach is a structured relationship with private nursing homes, including 15 in Kerry.

“During covid, there was a lot of outbreaks [in nursing homes], and then this expert group reported and it was obvious there were deficiencies in the care in nursing homes. Then we were asked to step in,” he said.

ICPOP nurses can now give intravenous drip treatment for urinary or respiratory tract infections to residents; two common reasons for hospital admissions.

Both Dr Liston and Ms O’Donoghue acknowledge that the service is in its infancy, noting the challenge of an estimated 2,500 frail elderly in Kerry.

“If we could get each of our ANPs [advanced nurse practitioners] and our trainee ANPs case-managing 150 to 200 a year, you’d have some service then,” he said.

A booklet for GPs advises conditions treated include cognitive impairment, Parkinson’s Disease as well as falls, frailty, and concerns about polypharmacy. They work closely with University Hospital Kerry (UHK) supporting elderly people who do need the emergency department (ED) or hospital.

Last winter, they went into the ED alongside hospital staff, and estimate out of 60 patients given into their care, 43 were not admitted but received at-home care instead.

The key is an online shared folder on all their patients and accessible to relevant UHK staff.

“If a nursing home resident were to present into ED today, the team below in ED can look up our shared folder, and see the ICPOP team saw that patient before,” Ms O’Donoghue said.

“They would contact our team here and say ‘we’ve optimised her as well as we can, are ye happy to follow up?’ And we would do that piece.”

This can help reduce delays in discharging patients, another issue for the HSE with widespread concern at this reaching 604 delayed patients just before Christmas 2022.

Summing up the ICPOP approach, Dr Liston says it is about having the right team and being funded to do the work: “From my point of view, it’s fantastic”.

Nodding in agreement, Ms O’Donoghue said: “I love the idea of the older people being helped in their home. I think it is everyone’s wish and desire to stay in their home.”

'I had 14 falls in 12 months'

Sheila O’Sullivan, 78, does not hesitate when describing what a new health service in Tralee has done for her — the sparkle is back in her eyes and she is walking without fear of falling.

“I had about 14 falls in 12 months,” she says.

“The falls were when I was just out walking and I’d fall. It was frightening. I grazed my hands, broke my fingers, cracked ribs from a fall.”  Her GP referred her to the Kerry HSE ICPOP.

“They organised a brain scan, an angiogram, a heart monitor, everything,” says Sheila.

“And Alan, the nurse here, he suggested I come off the sleeping pills because he thought they might be interfering with my balance.” 

Under careful supervision, Sheila was weaned off them earlier this year. She could call the advanced nurse practitioner anytime, and says: “You’d feel better after coming off the phone.” She also saw a speech and language therapist and a physiotherapist.

“It’s brilliant coming in here,” she says. “You sit in one room, and everyone comes to you. You just stay in the room, everyone is pleasant and it’s relaxing. It’s not like being in hospital.” Her husband of 55 years noticed the difference.

“I’m marvellous now,” says Sheila. 

The hubby even said the brightness came back into my eyes.

“He used always say that’s what he admired about me, that I had laughing eyes even when I wasn’t laughing. He said they were ‘dead in my head’ so when I came off the sleeping pills, he noticed it.” 

Clinical lead Richard Liston said over-medication is common among his orthopaedic patients at UHK. He estimates around 60% of hip fractures he sees affect patients “who will have been on the drug she [Sheila] was on and that we weaned her off”.

“So you’re preventing a hip fracture," Dr Liston says. "Now she’s off it entirely and that significantly decreases her falls risk.”

'I’m a different woman now, thank God'

Susan Nix, 78, was struggling so much with walking she said it was more like shuffling but is now hopeful she can travel to Spain next year to visit her daughter.

She is receiving physiotherapy care at home through the Kerry HSE ICPOP.

“I was falling, and I was actually losing my walk, so I was,” she said.

“My son had heard about Dr Liston here so I went to my own doctor and asked to come here. I couldn’t lift my feet, I was shuffling not walking. I’m a different woman now, thank God.”

The centre takes referrals from GPs for frail patients over 70 who are struggling with walking or other skills.

“They’re very good now here, they stuck by me and came out to the house to me,” she said.

“They come out to me all the time. I’ve met a dietician, Dr Liston, a physio, I met the whole crew.”

She said the home visits are crucial: “They come out three times a week. I can’t praise them enough. I walk with my stick and I won’t take any chances now. Before now I would take chances — they have shown me what to do.

“They listened to me.”

On her rare visits into the actual centre, she notices other differences to busy hospitals.

“It’s very relaxed,” she said, chatting over biscuits and tea in a rehabilitation room.

“It’s very homely. And there’s no smell of hospital about it. I’d tell my friends to go to their doctor and get sent here, I’d give it the height of praise.”

She lives in an apartment near one of her four sons and also has a daughter in Spain.

“I wouldn’t go out to her now, I have to wait ’til I get back my movement,” she said.

“When she [her daughter] lived there in the beginning I used to go out three times a year but, please God, I will get back now.

I will be safe now walking, I’m doing that next year, that’s my goal.”

Cork ICPOP centres

St Finbarr’s Hospital in Cork now hosts a hub sending doctors and therapists into older people’s homes as part of HSE plans to address the overcrowding crisis.

The hub, offering at-home treatment and nursing care among other changes, now sees just over 3,000 people a year across the southside.

In a recent example of why these reforms are needed, it emerged only 50.9% of over-75s were discharged or admitted to hospitals nationally within nine hours of arriving at an ED during January compared to a HSE target of 99%.

Consultant geriatrician Bart Daly works in Cork University Hospital and at the Cork southside ICPOP hub.

“Sometimes when somebody goes to hospital it’s because they are in crisis and don’t have another option,” he said.

“Whereas hopefully as this develops, we get better at seeing these things and advance planning for them, and providing some of that care at home.”

It is about having options for treatment when suitable, Dr Daly said.

“Also obviously the impact for an older person of being on a trolley — you are more at risk of delirium, of losing your strength, of getting infections,” he said.

“Hospitals deliver excellent care but older people can be more vulnerable to the side-effects of being in hospital, so with the ICPOP system we are able to offer some of that care at home.”

Patients can be referred for a range of conditions including frailty or memory issues with rapid response access also available.

“We’ve all that in Finbarrs, and we’re linking in with CUH and the Mercy depending on where the patients are coming from,” he said.

Cork also has ICPOP hubs in the north city, on the St Mary’s Health Campus, with another planned for Mallow.

For him, the project means spending his working days outside the hospital — a stark change from when he started as a geriatrician.

“Most of the programme is delivered by the GPs and primary care team, where there is a need for the next level of support, we step in,” he said.

In a recent presentation to the HSE enhanced community care conference, Dr Daly quoted patients who have used the Cork service.

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“They made me feel much happier that I knew someone was coming about me. You know, caring for me, like,” one person said.

A family member of another patient said: “They took over everything in their hands and everything was looked after and dealt with, like there was no pressure on the family.”