Kilmainham

Royal Hospital Kilmainham
Forum for
National Clinical
& Integrated Care
Programmes
18th October, 2016
Main event 10:30—15:30
Networking 15:30—16:30
The journey to
person-centred
integrated care
-
- NEW WAYS OF
WORKING
Details in this brochure are correct as
of 3rd October 2016 and may be
subject to amendment.
Hosted by:-

Welcome
Dear colleagues and friends
A very warm welcome to the HSE’s second Integrated Care event—
to those in the room here today at the Royal Hospital Kilmainham
and those who are joining us via the live webcast.
The Forum seeks to expose participants to ‘new ways of working’,
in the context of a person-centred integrated care framework, and
to explore how roles are developing nationally and internationally.
The idea of our Forum is to provide a point of engagement for
service providers to explore current and evolving roles. The parallel
sessions in the afternoon will consist of live examples of ‘new ways
of working’ within and outside of the National Clinical and
Integrated Care Programmes in Ireland. The context will be set in
terms of strategic plans (ICT, Policy, HR) and User requirements
from the morning session.
I hope you find the day both enjoyable and informative.
Any feedback? You can reach us at: Email: nationalcsp@hse.ie or
place a ‘poster’ on the ‘graffiti wall’ designed especially for your
messages on the day - we’d really welcome your opinions, ideas
and questions.
Regards
Áine
Dr. Áine Carroll
National Director for Clinical Strategy & Programmes
Health Service Executive
You can interact with us on:
https://twitter.com/cspd_hse
(Include # icpireland2016 in your tweets)

Programme
09.30 TEA / COFFEE
+ Poster viewing
10:30 Dr. Stephanie O’Keeffe
National Director, Health and Wellbeing Division, HSE
10:40 Dr Áine Carroll
National Director, Clinical Strategy & Programmes Division, HSE
Served in the chapel (includes
light refreshments). Posters are
on display in the chapel
Opening address
Integrated Care— the national and
international scene.
11:00 Richard Corbridge
Chief Information Officer, HSE
Yvonne Goff
Chief Clinical Information Officer, HSE
11:20 Rosarii Mannion
National Director, Human Resources Division, HSE
11:40 Greg Price
Director of Advocacy and Assistant National Director, Quality
Improvement Division, HSE
11.50 Michael Brophy
Patient Representative
12:20 Panel Discussion
Technology and integrated care in
Ireland
Facilitating new ways of working;
People Strategy and integrated
care
Service User Perspective -
Introduction
Service User Keynote
13:00 LUNCH Light lunch : served in the chapel.
13.45 PARALLEL PRESENTATION SESSIONS (3 simultaneous sessions):
Session 1. New Ways of Working
• Back on Track Programme – Vanda Cummins
• Collaborative Care Planning: Introduction to an
innovative approach to Care Planning in Adult Mental
Health – Patrick Gibbons
• DBT Steps-A: Inter-agency Collaboration to Promote
Positive Mental Health in Adolescents – Caitriona O’Malley
Session 2. Working across boundaries
• A community virtual ward model to support older
persons with complex health and social care - Clare Lewis
• Palliative Care Needs Assessment (PCNA) as a
cornerstone to implementing an Integrated Model of
Palliative Care Provision - Margaret Codd
• Development of a collaborative catheterisation service
for community clients through extending nurses' roles and
redesigning service delivery - Gwen Regan
Session 3. The process of care delivery
• The CReW Programme: How to Enable Multi-disciplinary
Teams to Design Integrated Care Models- Alison Enright
• The Cork Integrated Falls Service: Hospitals & community
working together to improve falls management pathway
for patients-Sheena McHugh
• Open Dialogue Implementation in HSE Mental Health
Services - Iseult Twamley
15:00 Dr. Nick Goodwin
CEO, International Federation for Integrated Care
15:10 Dr Aine Carroll
National Director, Clinical Strategy & Programmes Division, HSE
Session 1 presentations
to be held in the Main
Hall
Session 2 presentations
to be held in Breakout
Room 1
Session 3 presentations
to be held in Breakout
Room 2
Integrated Care in Ireland, Part of
an International Family
(including Call for Abstracts for
ICIC17)
15:10 Presentation of Prize for
Best Poster
15:15 Closing address (including
feedback from the parallel
sessions)
15:30 NETWORKING HOUR Light refreshments served in the
Chapel.

Speakers
Dr. Stephanie O’Keeffe is National Director of the Health and Wellbeing Dvision in
the HSE. Dr Stephanie O’Keeffe is a social psychologist and has worked for the
past 14 years in the health service. She has specific expertise in national health
strategy development, implementation and evaluation. The Health and Wellbeing
Division currently has 1500 staff and an annual budget of €200m. Within the
Division there are several operational areas including public health and health
protection, environmental health services, health promotion & improvement,
health intelligence and national screening services.
Dr Stephanie
O’Keeffe
National Director,
Health & Wellbeing
Division, HSE
Dr. O’Keeffe previously was the first Director of the new Health and Wellbeing
Programme in the Department of Health where she led out on the development
of Ireland’s first intersectoral population health framework, Healthy Ireland. Dr.
O’Keeffe is a former Director of the Crisis Pregnancy Programme where she
worked for ten years. She has a Bachelors Degree in Psychology from Trinity
College Dublin, an MSc in Psychological Research Methods and Assessment and a
PhD in Psychology from the University of Surrey in the UK.
Since 2012, Áine has overseen a growing number of National Clinical Programmes,
today totalling some 33, and witnessed how their clinically-led, evidence-based
approach to system reform has changed, and continues to change, how care is
being delivered in Ireland through improved and standardised patient care.
Dr Áine Carroll
National Director,
Clinical Strategy &
Programmes
Division, HSE
In mid-2015, the Clinical Strategy & Programmes Division started working with the
Programme for Health Service Improvement to develop and implement a major
programme of health and social care reform for the Irish people through the
development of Integrated Care Programmes for older people, chronic disease,
children, patient flow and maternity. These programmes are essential to
sustainable health and social care services for the future. They will tackle the
most pressing challenges whilst improving outcomes and experiences for the
greatest number of patients.
Prior to her appointment, Dr. Carroll was the Clinical Lead of the Rehabilitation
Medicine Programme. She is a Consultant in Rehabilitation Medicine, past Chair
of the Medical Board of the National Rehabilitation Hospital, President of the Irish
Association of Rehabilitation Medicine and Associate Professor at University
College Dublin School of Medicine. Her works on a wide variety of topics are
widely published and she regularly presents at national and international
conferences.
Richard Corbridge
Chief Information
Officer, HSE
Richard Corbridge, Chief Information Officer for the Health Service Executive in
Ireland and previously from the NIHR Clinical Research Network. Richard has a
wealth of experience in the Health and Clinical Research sector leading various
informatics delivery elements; business change, benefits management and
Information security projects. He has specialised in IT development, procurement
and implementation across national and local health care arenas in the UK for
more than fifteen years. Richard has delivered a wide range of systems and
process to aid with the provision of health care and research, these range from
delivery of the first primary care messaging system to innovation within a care
trust to deliver a health and social care single assessment process and onto the
modernisation of the information systems infrastructure for clinical research in
England.
At the end of 2014 Richard left his position as CIO of the National Institute for
Health Research specifically the Clinical Research Network (NIHR CRN). This
division was responsible for providing Information Systems and Business
Intelligence to a workforce of around 10,000 research related staff in the NHS.

Speakers
Yvonne Goff
Chief Clinical
Information Officer,
HSE
Yvonne Goff is the Chief Clinical Information Officer of the Health Service
Executive. A radiographer by background, she has over 18 years of experience in
the Health Sector with five of these directly involved in Informatics. Having
completed an MSc in Health Informatics (TCD) in 2010 she joined the national
implementation team of the NIMIS project as both a project manager and subject
matter expert. In this role Yvonne has driven the implementation of PACS/RIS
systems into a large number of hospital with a broad range of complexities.
Having been a key driver of one of the largest eHealth projects in Ireland to date,
Yvonne has developed an expertise in project delivery in difficult environments.
She has proven ability in driving process change and meeting targets, while at the
same time possessing an understanding of the clinical and patient needs for such
developments. She has presented at major international conferences on such
aspects.
In 2015 Yvonne was appointed as Chief Clinical Information Officer for the Health
Services Executive (Ireland). In this role, and previously, she has supported and
driven the need for progression of eHealth solutions across Ireland. She has an
inherent knowledge of the needs of the clinician and the patient, but sees the
benefits in progressing aspects such as standardisation, quality and safety, and
effective and efficient system implementation. She currently coordinates the
Council of Clinical Information Officers (HSE) which provides clinical governance to
the delivery of eHealth solutions.
Rosarii Mannion has over 15 years of human resources experience including
management experience in Community and Hospital Services in the HSE. She has
held a number of senior management roles, her most recent posts being Assistant
National Director Human Resources, Dublin North East and Group HR Director in
RCSI Hospitals.
Rosarii Mannion
Rosarii is a Chartered Fellow of the CIPD, a qualified Mediator, Conflict Coach and
holds a BA, HDip, MA and MSc.
National Director,
Human Resources
Division, HSE
Greg is Assistant National Director in the Quality Improvement Division of the HSE
following an extensive career within health and social care services. In his current
role, Greg leads a team who are committed to listening, understanding and
responding to the voice of the public.
Greg Price
Assistant National
Director, Quality
Improvement
Division, HSE
This work is done both in a frontline capacity through direct engagement with
people who use and provide health and social care services and also through the
development of policy, resources and initiatives. Greg is committed to ensuring
that patients, service users, families and carers are equal partners in the planning,
design and delivery of services.
Greg has a BL from The Honorable Society of King’s Inns, an LLB (Honours) Law
from Griffith College Dublin and an MBA from the Open University. He is an
accredited mediator and facilitator. Greg has a particular interest in legislation,
policy development and mediation

Speakers
Michael Brophy is a former Senior Investigator with the Office of the Ombudsman.
In that capacity he had functional responsibility for the examination and
investigation of all complaints received by the Ombudsman about the public
health service. In the course of this work he qualified as a Barrister.
Michael currently conducts complaint investigations and reviews, on an
independent basis, under the statutory complaints process for the public health
service introduced in the Health Act 2004.
Michael Brophy
Patient
Representative
Michael serves as a lay member of the Fitness to Practice Committees with the
Medical Council and an Bord Altranais (Nursing Regulatory Board). He has acted as
a lay observer with the National Board of the College of Emergency Medicine in
Ireland and a representative of the public interest with the Irish College of
General Practitioners (ICGP). He is currently acting as Chairperson of the HSE
National Patient and Service User Forum.
Michael is a member of Hearts in Healthcare, a network of individuals who are
committed to the re-humanisation of healthcare on a worldwide basis. In his work
in this area he has designed and facilitated educational interventions centred on
the value of compassion for healthcare staff in a variety of settings throughout
Ireland.
Nick was the co-founder of IFIC in October 2011 and became its first Chief
Executive Officer in March 2013. Nick is also the Editor-in-Chief of IFIC’s openaccess
and impact rated scientific periodical the International Journal of
Integrated Care.
Dr. Nick Goodwin
CEO, IFIC
(International
Foundation for
Integrated Care)
Nick holds a range of research, educational and consultation roles worldwide.
These international commitments include several European R&D projects such as
the EU FP7 Project INTEGRATE, the Horizon 2020 project SUSTAIN and the ICT-PSP
projects SMARTCARE, BEYOND SILOS, and CAREWELL. Nick is an active member of
the European Innovation Partnership on Active and Healthy Ageing B3 Action
Group on Integrated Care.
Nick has also been working with the World Health Organisation to support the
development of its Global Strategy on People-Centred Integrated Health Services
and is on the Expert Advisory Team to WHO Regional Office for Europe’s
Framework for Action Towards Coordinated/Integrated Health Services Delivery
(CIHSD) leading work related to change management and adoption of integrated
care in policy and practice.
Nick has also worked as an international consultant to the Agency for Integrated
Care, Singapore; the Pan American Health Organisation, Washington; the WHO’s
Western Pacific Regional Office; and to NHS England’s Better Care Fund Support
Programme.

Posters
TITLE
A Feasibility Study to Evaluate the Benefits of the Outpatient Cardiac
Rehabilitation Model for Survivors of TIA and Stroke.
A Hospital Without Walls – developing a strategy for integration
through collaboration
U&ME-A
A 'New Way of Working ‘ with Mental Health and Substance Abuse
Disorders in HSE South
Action Van Service – A Collaborative Approach to Patient Safety and
Facilitating Discharge from Hospital
Adaptation and implementation of a Paediatric Early Warning System
(PEWS) resource to support parents and carers to communicate
concerns about their child’s condition (NCP Paeds and Neonate)
Alzheimer’s Café Bray - Person-Centred Integrated Care
Balance Matters - A step towards integrated care
Becoming More Person-Centred
Bringing Hepatitis C Virus (HCV) assessment and treatment from
hospital to the community to improve uptake among people who inject
drugs (PWIDs).
Chronic Disease in the Emergency Department: The missing link in
integrated care? (NCP Emergency medicine with involvement of NCP
COPD)
Closing the loop: Integrating emergeny care plans into electronic
patient record for psychiatric presentations to the Emergency
Department
Community Medicine for Older Person’s Nursing Home (NH) Liaison
Service: An Integrated Model of Care between the Acute Hospital and
the Nursing Home Sector
Criteria Led Discharge (CLD) – What Matters to Staff - Preparing the
Multidisciplinary Team, Developing Knowledge & Competence
CONTACT
Ruth Coleman
Amy Anslow
Brid Mooney
Jo Cannon
Rachel MacDonell
Carol de Wilde
Vanda Cummins
Caroline Doran
Des Crowley
Gerard McCarthy
Rosie Plunkett
Jonathan O Keeffe
Richard Walsh

Posters
TITLE
CONTACT
Development of Hip/Knee Pathway between Primary and Secondary Care
Aisling Brennan
Establishing a memory clinic
Fermoy Trialogue Connections – Open Dialogue Forum
Mary Hickey
Noel Parsons
Frail Intervention Therapy Team (FITT): Integration of Early
Interdisciplinary Assessment in the Emergency Department.
Admission Avoidance: Health and Social Care Professions rise to the
challenge
Immunoglobulin Replacement Therapy in Immunodeficient Adults in
Ireland – towards Patient Centred Care
Implementation of a Standardised Coordinated Critical Care Nurse Career
Pathway (NCP Critical Care)
Implementing a Group Physiotherapy Service in Outpatient Primary Care:
A Healthcare Improvement Initiative
Implementing Respiratory Integrated Care: the Future for COPD Diagnosis
and Management?
Eleanor Alexander
Rosie Quinn
Mary Keogan
Una Quill
John Nwobo
Patricia Davis
Improving the Care of Patients with Sepsis – a National Approach
Information and Exercise promotion initiatives for the Irish Idiopathic
Pulmonary Fibrosis population
Integrated Care Pathways Between Heart Failure Services And
Community Intervention Team Reduces Patient Admission Rates To
Hospital.
Integrating Care through the National Clinical Programmes - A
collaborative Approach to Patient Safety (Medicines Management
Programme)
Celine Conroy
Petra Grehan
Norma Caples
Sarah Clarke

Posters
TITLE
CONTACT
Introduction of a primary care formulary to a nursing home
Nick Flynn
Management of Adult Malnutrition in the Community- The Midlands
Model
Sharon Kennelly
National Clinical Guideline No 6: Sepsis Management - A Quality
Improvement Initiative (NCP Sepsis)
Christina Doyle
National Drugs Rehabilitation Framework (NDHF)
Aoife Davey
Nursing Home to Acute Hospital Transfer Letter
Jean Barber
Oak Port Haven – Sanctuary and Care for All
Dave Lynch
OUCH! – Osteoarthritis; You Can Help!!
Our Service Our Say
Home Enteral Nutrition Service in North Dublin
Caitriona McGuinn
Bridget Harney
Niamh Maher
Enable Ireland, Cork - Orthopaedic Care Pathway
Gillian O Dwyer
Patients for Patient Safety Ireland
Percutaneous endoscopic gastrostomy tube related complications:
Dietitian Led PEG Service
Caroline Costello
Cathy Keenan

Posters
TITLE
CONTACT
Physiotherapy post fracture : An integrated approach to delivering an
Orthopaedic Physiotherapy service in Primary Care in Cavan, Monaghan
Paula Gallagher
Planting the seed: introducing advance care planning information into a
Pulmonary Rehabilitation Programme– a collaborative project
Rehabilitation without Walls – Reconfiguration of a National Paediatric
Service
Stepping Care - Using stepped-care to improve access to Psychological
Resources
Bettina Korn
Anne O Loughlin
Marie Carey
Successful application of a cross-sectoral integrated care approach to
Drug and Alcohol Services and Homeless services – the experience from
HSE-South
The Consequences of Using Technology to Improve Diagnosis in an Infant
Orthopaedic Service: How a Change in Practice Led to New Ways of
Working Together
The Effectiveness of a Physiotherapy Triage Clinic in Paediatric
Orthopaedics
Evaluation of a GP > Out-of-Hours Palliative Care Handover Form
Joe Kirby
Margaret Mason
Marie O Mir
Marie Lynch
The Integrated Critical Care Pathway
Michael Power
The Integration of Community and Acute Children’s Eye Services in
Galway 2016
Geraldine McBride
“What Matters to You?” Enhancing Compassionate Person-Centred Care
Deirdre Lang

Posters
TITLE
The National Healthlink Project – Supporting Healthcare in Ireland
CONTACT
Bronagh Kennedy
The National Rare Disease Office (NRDO): a patient focused approach to
providing Integrated Care
The role of the community-based Clinical Nurse Specialist in supporting
the delivery of integrated diabetes care: A cross-sectional survey
University Hospital Waterford and The Productive Operating Theatre: A
Productive Quality Improvement Partnership
Debby Lambert
Sheena McHugh
Lorraine Murphy
Valuing staff knowledge and creativity: Using Staff Listening and a Front
Line Ownership Methodology to improve quality
Juanita Guidera
‘What Matters to You’ Day: Our Experience in Beaumont Hospital
Anne Healy