Mwch 25017 Clinical Nurse Specialist

In line with Sláintecare (2017) and the Department of Health's Capacity review (2018), a shift in healthcare service provision is now required to place the focus on integrated, person-centred care, based as close to home as possible.
In order to enable this, the Integrated Care Programme for the Prevention and Management of Chronic Disease (ICPCD) is supporting the national implementation of a model of integrated care for the prevention and management of chronic disease as part of the Enhanced Community Care Programme (ECC).
The Model of Care for the Integrated Prevention and Management of Chronic Disease has a particular focus on preventive healthcare, early intervention and the provision of supports to live well with chronic disease.

The investment in the ECC programme will be delivered on a phased basis with a view to national coverage being achieved within a two- to three- year period.
Three priority areas have been identified as follows:
Structural reform of healthcare delivery within the community with Community Health Networks (CHNs) becoming the basic building blocks for the organisation, management and delivery of community services across the country; Creating Specialist Ambulatory Care Hubs within the community to support primary care management of chronic disease and older people with complex needs; Scaling Integrated Care for Older People and Chronic Disease through the recruitment of specialist integrated care teams including Frailty at the Front Door Teams.
The focus is on providing an end-to-end pathway that will reduce admissions to acute hospitals by providing access to diagnostics and specialist services in the ambulatory care hubs in a timely manner.
For service users who require hospital admission, the emphasis is on minimising the hospital length of stay, with the provision of post-discharge follow up and support for people in the community and in their own homes, where required.
A shared local governance structure across the local acute hospitals and community will ensure the development of a fully integrated service and end-to-end pathway for individuals living with chronic disease.

The ECC Programme is underpinned by a set of key principles including:
Eighty percent of services delivered in Primary Care are through the GP and CHNs; Identifying and building health needs assessments at a CHN level (approximate population of 50,000) based on a population stratification approach to include identification of people with chronic disease and frequent service users, thereby ensuring the right people get the right service based on the complexity of their health care needs; Utilisation of a whole system approach to integrating care based on person centred models, while promoting self-care in the community; The Older Persons and Chronic Disease Service Models set out an end to end service architecture for the identification and management of frail older adults with complex care needs and people living with chronic disease; Learning from, and delivering services, based on best practice models and the extensive work of the integrated care clinical programmes to date, particularly in the areas of Older Persons and Chronic Disease; Embed preventive approach to chronic disease into all services; Availability of a timely response to early presentations of identified conditions and the ability to manage appropriate levels of complexity related to same in the community; Resources applied intensively in a targeted manner to a defined population, implementing best practice models of care to demonstrate the delivery of specific outcomes and sustainable services; The need to frontload investment, coupled with reform to strengthen community services.
Diabetes in Ireland Diabetes is a serious global public health issue which has been described as the most challenging health problem in the 21st century.
Cases of diabetes have progressively increased worldwide; between 1980 and 2008 there was a two-fold increase in the number of adults with diabetes.
Type 2 diabetes is the main driver of the epidemic, accounting for approximately 90 % of all cases.
In Ireland, in people aged 18 years and over, the prevalence of diagnosed diabetes increased from 2.2 % in 1998 to 5.2 % in 2015; representing an absolute mean increase of 0.17 % per year.
In 2015, the incidence of diagnosed diabetes was 0.2/100 population.

Diabetes places a significant burden of care on the individual, health care professionals and the wider health system.
Individuals with diabetes are two to four times more likely to develop cardiovascular disease relative to the general population and have a two to five-fold greater risk of dying from these conditions.
Diabetes is a significant cause of blindness in adults, non-traumatic lower limb amputations and end-stage renal disease resulting in transplantation and dialysis.
In the Irish Longitudinal Study on Ageing (TILDA), among people aged 50 years and over with type 2 diabetes, 26% reported microvascular complications and 15% reported macrovascular complications.
This means that as well as being an important public health issue, Type 2 diabetes is a huge financial burden to the Irish health service where diabetes care consumes up to 10% of the Irish healthcare budget.

National Clinical Programme for Diabetes The National Clinical Programme Diabetes (NCP Diabetes) was established in 2010 under the HSE's Clinical Strategy and Programmes Division.
Working under the direction of the National Clinical Advisor and Group Lead (NCAGL) for Chronic Disease and supported by the RCPI Diabetes Clinical Advisory Group, the aim of the NCP Diabetes is to save the lives, eyes and limbs of people living with diabetes in Ireland by:
Decreasing morbidity and mortality through correct and early diagnosis; Providing correct treatment based on best practice guidelines for treatment (self-management, primary care and secondary care).
Guided by the model of care for chronic disease, the NCP Diabetes aims to influence positive change and improve care for people living with diabetes across the entire spectrum of healthcare delivery: self-management support; general practice; specialist support to general practice; specialist ambulatory care; and hospital inpatient specialist care.

The role of the CNS will differ according to the needs and configuration of established diabetes services at each site.
The purpose of this Clinical Nurse Specialist, Diabetes Integrated Care post is to provide expertise and specialist nursing services to service users with Type 2 Diabetes both in the hospital outpatient settings and in primary care.
The post holder will liaise between acute diabetes services and integrated diabetes services in the community along with other agencies to deliver effective evidenced based care.
They will use resources efficiently to achieve the best possible outcomes in keeping with the National Clinical Programme Diabetes model of care and HIQA standards.

The person appointed to this post will work in Diabetes Integrated Care services.
The post holder will work as part of a multidisciplinary team delivering coordinated evidence based care for service users in primary care whilst liaising closely with secondary care.

Informal Enquiries: Ms.
Carmel O'Connor, Assistant Director of Public Health Nursing
Tel: 087 2939051
Email:
#J-18808-Ljbffr