When 87-year-old Fintan Mullally had two falls just weeks apart, it felt like going to hospital was the next step. Instead, his GP referred him to the Dublin Southwest Integrated Care Programme for Older People (ICPOP), a community based service supporting older people with complex needs.
Within days Fintan was seen by ICPOP case manager Linda Davidson Lee, who came to his home to carry out a comprehensive geriatric assessment.
For Fintan, the support was practical and immediate. Following this assessment he received a falls-clinic specialist nurse assessment, a 24-hour blood-pressure monitor and an occupational therapy home assessment that recommended a supportive chair. He also received a high-rise bed to make getting out of bed safer. A physiotherapist visited his home to guide him through a personalised exercise programme in his own living room.
The supports also helped Fintan remain socially connected. He is now a regular at the local Gaelic Café, the Clondalkin Men’s Shed and local Leisure Centre where he swims.
ICPOP provides comprehensive geriatric specialist assessment and coordinates care for people aged 65 and older living with frailty, falls, mobility issues, memory concerns or reduced independence. The service acts as a bridge between local GPs and hospital services, with the Dublin Southwest hub based in Clondalkin. The Dublin Southwest ICPOP team is made up of consultant geriatricians, registrars, advanced nurse practitioners, clinical nurse managers, occupational therapists, physiotherapists, therapy assistants, medical social worker and administrative staff who focus on supporting older people to maintain their independence and live well at home for as long as possible.
Linda explains:
“Essentially, we provide a one-stop-shop for older people with complex needs and the integrated approach leads to better outcomes for patients. When we meet a patient, we carry out a comprehensive geriatric assessment to identify their needs, which is seen as gold standard in older person assessments. We can also refer for further diagnostic, social care and supports. A key aspect of the service is that we work together with the patient to identify and respond to their specific needs; to determine what matters most to them. We can then coordinate supports so they can be treated and supported at home, rather than in hospital.”
Frailty affects more than 20% of older adults in Ireland and is linked to increased hospital admissions and loss of independence. According to Dr Aoife Fallon, Consultant Geriatrician and Clinical Lead, Tallaght University Hospital/ Tallaght ICPOP Hub, services like ICPOP are helping to change that: “The real benefit is that older people can stay at home for longer, with more joined-up care. By using the supports available through ICPOP, we can manage many health needs in the community and help avoid hospital or nursing home admission.”
For Fintan, these supports have made it possible for him to continue living independently at home: “Linda coordinated everything,” he explained.
As the HSE’s Enhanced Community Care Programme continues to strengthen community services like ICPOP around the country, Fintan’s experience offers a snapshot of what joined-up, community-based care can deliver.
This development aligns with the HSE Corporate Plan stated priority of care delivered in the right place through enhanced community services – increasing the amount of care delivered in the community.