There was no ICT connectivity between the hospital, the CIT and GPs.Short description of practice change implemented: An ICT solution was developed and implemented in house that ensured the CIT service had up-to-date accurate patient information delivered efficiently. Software installed on secure electronic devices, allows the nurse real time access to a patient's summary record, and facilitates the recording of visit details while with the patient.Aim and theory of change: The aim was to support nursing teams in the community, and improve real-time communications between the hospital, CIT, GP and public health nurses (PHNs).Targeted population and stakeholders: The target population is a 480,278 catchment area covered by the CIT. Stakeholders include HSE management, hospital consultants, Directors of nursing, bed planners, discharge managers, PHN's, GP's and primary care teams (PCTs).Timeline: The development of the ICT platform was completed in conjunction with the implementation of the CIT service. An iterative approach was taken to the development of the software and configuration is enhanced when warranted through feedback provided by users.Highlights: (innovation, Impact and outcomes) Continuity of care is a central aspect for the CIT. Improved real-time communications underpinned by ICT now exist between all the stakeholders involved in the patient's care. The CIT ICT platform is linked to GP surgeries, acute hospitals, out-of-hours service and public health nursing to facilitate the seamless and efficient flow of information.The Hospital can refer a CIT patient through a secure weblink form connecting the HSE network to the CIT network, while the GP can generate an electronic referral through their in house software using the National referral template, via the national messaging system, Healthlink. On discharge from the CIT, an electronically generated summary is sent to the GP, the hospital or the public health nurse (PHN) as appropriate.Comments on sustainability and transferability: The ICT platform is built on the core principle that it is scalable to increase capacity as required as well as facilitating interoperability and configurability as the service develops.
Collier, Dorcas 2020 Integrated Rapid Discharge Planning for palliative patients and their families/carers when a patient expresses a wish to die in their home environment.
Purpose:To expand and develop the Caredoc integrated community intervention team (CIT) to engage with further stakeholders and to empower healthcare services and workers to support coordination and cooperation for patients, general practitioners, community services and the acute hospital.
Objectives:-To expand the Caredoc CIT model of care to incorporate hospitals and services in the Southeast of Ireland -To inform and describe the model of care to hospitals, GPs and patients -To support all stakeholders in moving to a new way of care -To ensure all stakeholders are comfortable with the transition -To empower all stakeholders by ensuring everyone involved is aware of their role and the role of others -To securely integrate patient notes across all stakeholders to ensure continuity of care and safetyThe Caredoc CIT provides an acute nursing service to patients in their own home, treatment centre or care facility in the community who would traditionally be treated in the hospital setting. The service supports patients, primary care and hospital services by utilising and optimising resources to facilitate early hospital discharge and hospital avoidance.
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