Location of Post

Cavan Monaghan Integrated Healthcare Area – Cavan - 1 Permanent, 1WTE.

A panel may be formed as a result of this campaign for Operational Team Lead from which current and future, permanent and specified purpose vacancies of full or part-time duration may be filled.

Informal Enquiries

Martin Collum,
General Manager,
Community Healthcare Area Cavan
Phone: 086 8236177
Email: martin.collum@hse.ie 

Purpose of the Post

Background to the Post

The Operational Team Lead Integrated Care Older Persons will play a key role in implementing the Service Model for Older Persons for Cavan/Monaghan IHA.

While not directly involved in delivery of care, they will have experience in the delivery of older persons’ services that helps to manage a patient's care journey

and signpost patients to the correct service, coordinate patients' treatment plans, connect them with health care
professionals, and evaluate their progress

As outlined above, the need to reform the healthcare services in Ireland in order to provide a more sustainable, integrated and patient-centred

approach has come to the fore in recent health policies and strategies. The post must be congruent with the requirement of Sláintecare, HSE National framework for the

Prevention and management of chronic disease and the Enhanced Community Care Business case.

Integrated care requires health and social care services to work together across different levels and sites in order to provide end-to-end care

that meets patient need. As described in the Sláintecare report (2017), integrated care involves:

• Ensuring appropriate care pathways are developed with a focus on person-centred service planning to ensure services are built around patients;
• Supporting timely access to all health and social care services according to
medical need; and,
• Patients accessing care at the most appropriate, cost effective service level with a strong emphasis on prevention and public health.

Implementing integrated services and pathways for older people with complex health and social care needs to enable a shift in the delivery of care from

the acute hospitals towards community based planned coordinated care. The objective of the National Integrated Care Programme for Older People (NICPOP) is to improve the quality of life for older people

by providing access to integrated care and support that planned around their needs and choices, enabling them to live well in their own homes and communities (HSE, 2017).

The ICPOP service is a specialist multidisciplinary service primarily targeting and managing the complex care needs of the older person with multiple co-morbidities across a continuum of care.

The overall aims of the service are to:

• Provide a specialist geriatric opinion using a multidisciplinary approach to support older people with complex care needs.
• Develop a person-centered care planning approach that supports robust and timely communication across care settings.
• Support appropriate and timely reduction of Emergency Department (ED) attendance through the development of care pathways that support GPs

   and others in assessment of older people with escalating care needs.
• Provide support and education to the older person, carers and healthcare professionals.

The Operational Team Lead Integrated Programme Care Older Persons role is multifaceted:

1. The post holder is responsible for the day-to-day operational management of the Integrated Care Team (Older People) and HUB functions.
2. The post holder will develop an Operational Policy that captures the functions of the hub and the MDT roles and functions. The Operational Policy will act as a key reference point,

     setting out the key functions of the Hub and specialist OP MDT.

3. The post holder will operationally manage all the staff in ICPOP Cavan Monaghan. Professional Reporting for all disciplines

    will continue with the relevant HOD/ DPHN / DON OPS or other as appropriate. This will be reflected in a management matrix to be signed off locally,

    which will set out the basis of the working relationship between local Heads of Discipline and the Team Co-ordinator.

4. The post holder will support the development of dynamic linkages between Cavan Monaghan ICPOP Ambulatory Care Hub (HUB), the Community Healthcare Networks (CHNs) and the acute hospital,

    to address the needs of the population of older people living with frailty in a CHN as per the National Integrated Care Programme for Older Person (NCPOP) model.

5. The post holder will ensure that team structures are attended to in order to ensure that the service is consistent with recognized best practice in team functioning.

   This includes MDT clinical reviews and team operational meetings.

6. The post holder will play a pivotal role in collaborating with the Community Healthcare Network Manager and the ICPCD Team Co-Ordinator to adopt a population

    based approach to services, completing a population stratification and identifying those clients most at risk, for management within the CHN and Specialist Teams

7. The post holder will work with Community Healthcare Network (CHN) colleagues including wider health and social care providers (primary and social care,

    community and voluntary organisations, local authority to support older people to live well at home

8. The post holder will establish a proactive approach to caseload management to ensure team capacity and flow is maintained.

    This will for example will include a database of at risk individuals and or/by creating a virtual hub approach.

9. The post holder will work with the Consultant Leads /Project MDT and existing outreach /in reach services to develop integrated criteria for referral

     and on- going support ensuring a seamless continuum of care for the patient.

10. The post holder will ensure that all services are operating optimally and timely care is being provided

    to all Older Persons accessing the healthcare professionals at all levels of the service.

11. The post holder will develop and operationalise care pathways as per the service model in tandem with clinical lead and CHN leads (network manager and GP lead).

    This will address key pathways as a priority (Falls, Memory, Dementia) to ensure that vulnerable older persons clinical needs (acute or chronic) are assessed promptly in the

    ambulatory care / community setting (integrated approach with the acute hospital as required) and that they are supported in accessing the appropriate care pathway in a timely manner.

12. The post holder will ensure older persons are facilitated to understand their care needs and to work in partnership with the Multidisciplinary Team (MDT) and wider community

    to ensure the provision of care in an ambulatory model and at home when possible.

13. While clinical functions are desirable to the role of the operational team lead integrated care for older persons,

the priority functions he/she performs is coordination of team and hub operations ensuring the provision of a seamless integrated service

with a multidimensional and multidisciplinary input for the older person across the care continuum.

Eligibility Criteria

Qualifications and/or Experience

Professional Qualifications, Experience, etc.

Candidates must have at the latest date of application:

• A significant record of accomplishment in leading and implementing service improvement within a health system.
And
• Have substantial experience, ideally in the speciality area (Older Persons Services)
And
• Demonstrate evidence of continuing professional development at the appropriate level.
And
• Experience of interacting with multiple internal and external stakeholders as relevant to the role.
And
• Have the requisite clinical, managerial and administrative knowledge and ability (including a high standard of suitability and management ability)

  for the proper discharge of the responsibilities and duties of this role.

Health
A candidate for and any person holding the office must be fully competent and capable of undertaking the duties

attached to the office and be in a state of health such as would indicate a reasonable prospect of ability to render regular and efficient service.

Character
Each candidate for and any person holding the office must be of good character.

Post Specific Requirements

Knowledge of assessment and case coordination work within older persons service with people with

complex care needs who require community care and experience of/demonstrate the ability to engage a team to implement this in a systematic way.

Evidence of relevant management experience and in particular of older persons services, some of which must be

within an acute care and the community health environment

Significant knowledge of current issues and experience of working with older people with complex care needs within the community.

Understanding of the challenges of leading a complex change programme with significant technology and process change, interdependencies and HR challenges

Please see attached Job spec and additional campaign information:

3126CHCM Operational Team Lead ICPOP Job Spec

Additional Campaign Information