It is widely accepted that older people’s complex healthcare needs require integrated mental and physical health services. The importance of this integration is described in the Integrated Care Program for Older People (ICPOP). This is highlighted by the Sharing the Vision document, which states that joint care arrangements should be in place where possible to meet older peoples’ mental and physical health needs (DOH, 2020; DOH, 2022). The Specialist Geriatric Services Model of Care, Part 2: Mental Health Service Provision emphasises the need for mental health services ‘to build good working relationships with primary care, social care and geriatric medicine in particular’’ (NCPOP, 2019).
The ICPOP is a specialist community service, which provides geriatric assessment and multidisciplinary support in the community. It accepts referrals from both primary and secondary care and aims to be a ‘one-stop shop’ to support older people. In Clare, a single ICPOP service and a single Psychiatry of Later Life (POLL) service serve the entire county, with the two services co-located on a single campus. The Clare POLL team provides an inpatient POLL consult liaison (CL) service to Ennis Hospital, which is a ‘Model 2’ hospital (HSE, 2010), and St Joseph’s Hospital, a nursing home and rehabilitation unit.
From July 2023 to June 2024 inclusive, the majority of CL referrals from Ennis Hospital fell under the remit of the Clare POLL team (71.25%, n = 57, n = 80). The remainder (28.75%) fell under the remit of the general adult CL service. For the same period, CL referrals made up 21.43% (n = 81, n = 378) of all referrals to the Clare POLL team. Therefore, for this period, CL referrals made up a significant proportion of all referrals to the POLL team, and the majority of CL referrals from Ennis Hospital were for patients over the age of 65.
As part of the ongoing expansion of the Clare POLL CL service, from January 2024, we began providing an outpatient CL service with our ICPOP colleagues. This letter aims to describe a model of care for our newly developed ICPOP CL service. It may interest other POLL teams who wish to expand their CL service to include their local ICPOP service or other community specialist services.
In 2023, members of the Clare POLL and ICPOP teams met, to discuss integration options between the two services. Senior medical (Consultant, Senior Registrar or General Practitioner) and candidate Advanced Nurse Practitioners (cANP) members of both services met and collaborated on a pilot model of care, which began operating in January 2024. Integrated multidisciplinary meetings were held fortnightly, each team being represented by at least one senior doctor and one cANP. At these meetings, each team brought patient cases to discuss, for whom they felt the other team’s input may be helpful. For each patient, the consulting team could provide advice, arrange a consult (to see the patient and then advise), or to arrange a full referral and subsequent joint care.
Cases brought by ICPOP for discussion with POLL often resulted in advice about medications or linking patients with other supports. These cases were reviewed at subsequent meetings as needed until POLL’s input was no longer required. The POLL service also provided a CL clinic to ICPOP patients. These clinics were carried out by a POLL Senior Registrar. If required, follow-up could be provided in a future CL clinic. Patients with more complex needs requiring ongoing POLL multidisciplinary support were referred for joint care.
Cases brought by POLL for discussion with ICPOP could also receive advice or a referral to ICPOP for joint care. These cases often required full referral for joint care, as ICPOP’s geriatric multidisciplinary input was often required. Recommendations from both services were typically included in either service’s subsequent correspondence with primary care.
Joint teaching sessions were also set up for both POLL and ICPOP to attend. During the first teaching session, members of each multidisciplinary team explained their roles within their service. Subsequent joint teaching occurred every two months. POLL and ICPOP led alternate teaching sessions on topics related to both services.
The ICPOP CL initiative began in January 2024. From January to June 2024, there were 18 cases referred by ICPOP for discussion with POLL. These ICPOP referrals made up 31.58% (n = 18, n = 57) of the POLL CL referrals over these six months, and made up 10% (n = 18, n = 180) of overall referrals to the Clare POLL service for the same period. Of these 18, only four (22.22%) required joint care. Many ICPOP referrals to POLL required only advice (55.56%, n = 10) or a consult (22.22%, n = 4). Previous to this integration initiative, it is likely that many of these cases, which ultimately required only advice or a consult, may have resulted in a community referral to POLL.
Seven patients were referred by POLL to ICPOP via the integrated multidisciplinary care meetings, all of whom required joint care. Therefore, 11 patients benefitted from a streamlined pathway to joint care via the integrated multidisciplinary meetings. The characteristics of patients referred to the POLL CL service, whether from the inpatient setting or via ICPOP, are summarised in Table 1. For patients referred by ICPOP, low mood or anxiety (n = 10, 55.56%) were the most common reasons for referral, followed by issues surrounding diagnosis of dementia (n = 5, 27.78%) and behavioural symptoms of dementia (n = 3, 16.67%). This was markedly different to inpatient CL referral patterns (Table 1). Feedback from members of both the Clare POLL and ICPOP teams has been positive and integration was felt to be mutually clinically beneficial. Feedback on the joint teaching sessions was also positive.
Table 1. Clare POLL consult liaison referrals
CL = consult Liaison, POLL = Psychiatry of Later Life, ICPOP = Integrated Care for Older People Service, BPSD = Behavioural and Psychological Symptoms of Dementia.
In conclusion, the tangible benefits of this service development were a more streamlined pathway to joint care for patients requiring the input of both ICPOP and POLL, with 11 patients benefitting from this in its first six months. This service has also facilitated providing advice on patients to our ICPOP colleagues without a need for full referral for joint care (n = 14, 77.78% of referrals discussed). Staff feedback on the initiative has been positive from both services. In terms of time and resources required, it would not have been possible without the cANP’s of both teams, and buy-in from medical staff. The service development has continued to date.
Many national documents are calling for greater integration between POLL and other healthcare services (NCPOP, 2019; DOH, 2020; DOH, 2022). The authors believe there are potentially other models of care for integration between POLL and other community specialist services. The authors believe that the utility of future models of care will be an area of further research and service development.
Acknowledgements
The authors would like to acknowledge all the members of the Clare Psychiatry of Later Life service, all members of the Clare Integrated Care Program for Older People service, and all patients served by either of our services. We would also like to acknowledge Dr Elaine Dunne and Dr Coaimhe Lonegan, whose work setting up a similar service in Cork inspired our own.
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Competing interests
All authors declare none.
Ethical statement
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. The authors assert that the Ennis Acute Psychiatric Unit Audit Committee determined that ethical approval from the local Ethics Committee was not required for publication of this service evaluation. The authors have provided written confirmation of this from the Audit Committee and local clinical director.
