The HSE reports progress in improving healthcare for older adults and individuals with chronic diseases through the Enhanced Community Care Programme, which aims to bring services closer to home, reduce hospital admissions, and enhance patient care.
The introduction of Community Specialist Teams for older people in the West and North West region resulted in almost 28,000 individuals receiving care in 2024. Specifically, CST activity in Donegal and Sligo/Leitrim saw a 12.5% increase.
Across the West and North West, 85.5% of patients were discharged home following community-based interventions, including educational programmes on healthy eating, nutrition, and physical activity. Only 5% of patients required long-term care, with less than 3% needing acute care services. In Donegal and Sligo/Leitrim, this figure was 4.8%.
Community Specialist Teams, comprising nurses, physiotherapists, occupational therapists, speech and language therapists, social workers, and dieticians, under consultant geriatrician governance, provide a ‘one-stop-shop’ for older people with complex needs. These teams successfully managed the care of over 1,500 frail adults, avoiding unnecessary hospital admissions, with 55% of these adults seen in Donegal and Sligo/Leitrim.
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Enhanced Community Care: Improving Health Outcomes in HSE West and North West
The Health Service Executive (HSE) is making significant progress in improving healthcare for older adults and individuals with chronic diseases through the Enhanced Community Care (ECC) Programme. A key pillar of Sláintecare, the ECC Programme is bringing services closer to home, reducing hospital admissions, and enhancing patient care.
Minister for Health, Jennifer Carroll MacNeill TD, said: “I really want people to have access to as much care as possible in their home and in their community. The Enhanced Community Care Programme, a cornerstone of Sláintecare, is transforming patient care by expanding local healthcare services, reducing hospital dependency, and enhancing patient outcomes. This programme shows our commitment to delivering high-quality, patient-centred care that meets the evolving needs of our communities, in our communities.”
Key achievements in HSE West and North West included the following:
Strengthen integrated services for older people and reduce unnecessary hospital admissions
The introduction of community specialist teams (CSTs) for older people in the West and North West region has led to very positive results with almost 28,000 older people receiving care in 2024. In Donegal and Sligo/ Leitrim CST teams saw in increase in activity of 12.5% and in Galway, Mayo, Roscommon a 29% increase was recorded last year.
Community based interventions
In total across the West and North West 85.5% of patients were discharged home after community based interventions. These include educational programs to teach about healthy eating and nutrition or encourage physical activity. These health promotion programs may also help prevent or manage chronic health conditions, such as cardiovascular disease, hypertension, and type 2 diabetes.
Across the West and North West only 5% of patients required long-term care with , with less than 3% needing acute care services. In Donegal and Sligo/Leitrim only 4.8% required long-term care, while in Galway, Mayo and Roscommon only 4.9% required long-term care.
Community specialist teams include nurses, a physiotherapist, an occupational therapist, a speech and language therapist, a social worker and dietician, under the governance of a consultant geriatrician. This provides a “one-stop-shop” for older people with complex needs. Our CSTs successfully managed the care of over 1,500 frail adults, avoiding unnecessary hospital admissions. A total of 55% of these frail adults were seen in Donegal and Sligo/Leitrim and 45% were seen in Galway, Mayo and Roscommon.
Expanding Hospital Avoidance Initiatives
The Mobile X-ray service is benefitting over 600 nursing homes nationally, reducing the need for hospital visits. In the West and North West over 1,700 x-rays were completed using mobile x-ray services. A total of 95% of patients were treated at home, avoiding hospital transfers.
Enhancing Chronic Disease Management & Reducing Hospital Dependency
The ECC Programme is improving chronic disease care through specialist consultant support. The New Integrated Care (IC) Consultants and their acute based teams completed over 32,000 patient contacts in 2024. Almost 5,000 new patients received care through direct GP referrals and OPD waiting lists. In total over 3,000 were seen from OPD waiting lists, with 6% seen within two weeks. In the West and North West 97,000 patient contacts were made in 2024 and 18,800 referrals accepted.
Community & Voluntary Supports
Over 9,000 people were supported by ALONE, a voluntary partner, in facilitating co-ordinated support, visitation support, befriending, age friendly housing technology and community supports.
Strengthening Community Diagnostics & Therapy Services
- Over 42,000 radiology tests completed.
- Almost 36,000 NT-proBNP tests completed to detect new-onset heart failure.
Improving Multidisciplinary Care through the Community Healthcare Networks (CHNs) has resulted in increasing access to Therapy Services
- Almost 250,000 patient contacts were completed across the five therapy services, including Physiotherapy, Occupational Therapy, Dietetics, Speech & Language Therapy, and Podiatry.
- 59,000 patients seen for first-time assessments, an increase of over 4% from 2023, with notable increases in Physiotherapy and Dietetics.
Advancing Integrated Healthcare & Digital Transformation
The CHNs support team-based care as follows:
- The HSE Area Finder tool helps GPs refer patients to CHN teams via HealthLink.
- 13,000 e-referrals were made through HealthLink in 2024, improving patient coordination.
New Ways of Working for Integrated Care Consultants
- Over 300 virtual clinics were held, 80% focused on heart conditions.
- Overall, 85% reduction in hospital attendance for patients using Heart Virtual Clinics (HVCs), with GP-led care supplemented by specialist input.
Mobilising Remote Care Solutions
The national rollout of video consultations via Attend Anywhere is advancing the digitisation of community care services.
Commenting, Tony Canavan stated, “As the Regional Executive Officer for HSE West and North West, I am proud to witness the transformative impact of the Enhanced Community Care Programme in our region. With more older adults being discharged home following community interventions and significant advancements in chronic disease management, we are truly bringing healthcare services closer to home. Our efforts in expanding hospital avoidance initiatives, such as the Mobile X-ray service, and the innovative use of digital solutions like video consultations, demonstrate our commitment to reducing hospital dependency and enhancing patient care. These achievements reflect our dedication to delivering high-quality, patient-centered care, aligned with the principles of Sláintecare, and ensuring that the evolving needs of our communities are met with compassion and efficiency.”
