Clinical Nurse Specialist (CNS), Gerontology – Integrated Care(ICPOP)
Details of the Service
A significant programme of reform is underway in Services for Older Persons supported by the strategic direction set out under Sláintecare (2017) the Enhanced Community Care (ECC) business case (2019) HSE Corporate Plan (2020) National Service Plan (2021) and the National Clinical Programmes.
The Enhanced Community Care Reform Programme (ECC) is focused on the transformation of community care with an emphasis on establishing Community Health Networks and Specialist Community Teams working within Ambulatory Community Hubs. These plan and organise services for a defined population enable integrated care to be implemented shifting the focus away from acute hospitals towards a new model of specialist care in the community. The redesign of services allow new pathways to be developed between hospitals community services primary care health & wellbeing and voluntary sectors to develop new networks of care for Older People and people with Chronic Disease.
The investment in an Enhanced Community Care Model will be delivered on a phased basis with a view to national coverage being achieved within a 2-3 year period. Three priority areas have been identified as follows;
Structural reform with Community Health Networks (CHNs) becoming the basic building blocks for the organisation management and delivery of community services across the country.
Creating specialist ambulatory care hubs within the community for the management of chronic disease and older people with complex needs.
Scaling Integrated Care for older people and chronic disease through the recruitment of specialist integrated care teams across the care pathway including Frailty at the Front Door Teams.
The ECC Model is underpinned by a set of key principles including:
Eighty percent of services delivered in Primary Care are through the Community Networks.
Identifying and building health needs assessments at a Network level (approximate population of 50000) based population stratification approach to identify people with complex longitudinal care needs that require integrated care. This targets older people living with frailty and people with chronic disease who are high need service users thereby ensuring the right people benefit from care pathways that deliver care closer to home based on the complexity of their health care needs.
Utilisation of a whole system approach to integrating care based on person centred community models while promoting self-care in the community.
Learning from and delivering services based on best practice models in the community and the extensive work of the integrated care clinical programmes particularly in Older Persons and Chronic Disease services
Availability of a timely response to early presentations of identified conditions and the ability to manage appropriate levels of complexity related to same.
Resources applied intensively in a targeted manner to a defined population implementing best practice models of care to demonstrate the delivery of specific outcomes and sustainable services
The need to frontload investment coupled with reform to strengthen community services.
Embed a preventative approach into all services.
The Integrated Older Persons Service Model sets out the end to end service architecture for the identification and management of people living with chronic disease and frail older adults with complex care needs. The focus is on providing an end-to-end pathway that will reduce admissions to acute hospitals by providing access to diagnostics and specialist services in the ambulatory care hubs in a timely manner. For patients who require hospital admission the emphasis is on minimising the hospital length of stay with the provision of post-discharge follow up and support for people in the community and in their own homes where required. A shared local governance structure across the local acute hospitals and the associated CHO will ensure the development of a fully integrated service and end-to-end pathway.
The integrated older persons service is a specialist multidisciplinary service primarily targeting and managing the complex care needs of the older person with multiple co-morbidities across a continuum of care. The overall aims of the service are to:
Provide a specialist geriatric opinion using a multidisciplinary approach to support older people with complex care needs.
Develop a person-centred care planning approach that supports robust and timely communication across care settings.
Support appropriate and timely reduction of Emergency Department (ED) attendance through the development of care pathways that support GPs and others in assessment of older people with escalating care needs.
Provide support and education to the older person carers and healthcare professionals.
The Clinical Nurse Specialist General (Gerontology Integrated Care) as part of the Integrated Care Team will work closely with the Consultant Geriatrician and ICT team lead to develop and implement appropriate care pathways while working with primary care community care and acute care services.
The Clinical Nurse Specialist General (Gerontology Integrated Care) will work as part of the service which comprises physical clinics and an Outreach Team.
Six Health Regions have been established within the HSE on the basis of the geographical boundaries agreed by the Government in July 2019 and they will be operational from 2024.
Each Health Region will be tasked with population specific planning resourcing and delivery of health and social care services for the needs of its unique population. This will result in improved accountability and governance in terms of finance and performance while also bringing decision-making closer to the frontline.
Health Regions will enable and empower staff to provide services that are:
Integrated locally planned and delivered
Easier to access and navigate
Available closer to home
Health Regions are geographically-based units with clearly defined populations. They align community and hospital services within specific areas. The HSE will retain a strong but leaner central organisation with more service provision developed at a local level.
The HSE South West health region will manage and deliver all public health and social care services in Cork and Kerry. HSE South West includes all hospital and community healthcare services in the region.
This includes:
South / South West Hospital Group S/SWHG
Cork Kerry Community Healthcare CKCH
The Department of Population and Public Health is also now aligned with this health region
Services in the South West health region:
HSE Services working within this region include:
Acute Hospitals
Primary care services
Community services
Social care services
Health and social care professionals
Voluntary sector services
South / South West Hospital Group and Cork Kerry Community Healthcare became part of HSE South West health region on 3rd March 2025 and the transition to the new structures will continue throughout 2026.
Purpose of the Post
The purpose of this CNSp. General (Gerontology Integrated Care) post is to contribute to the improvement of the health care experience and outcomes for older people attending the Integrated Care Team across Older Persons Services. They will deliver care in line with the five core concepts of the role as set out in the Framework for the Establishment of Clinical Nurse/Midwife Specialist Posts 4th ed. National Council for the Professional Development of Nursing and Midwifery (NCNM) 2008.
The CNSp. General (Gerontology Integrated Care) will focus on assessing and promoting the health and function of older people living with frailty assisting them in preventive and rehabilitative processes for a set time frame as a member of the Integrated Care Team. The CNSp. will link with other practitioners and services such as primary care respite day services and home support providers and will also support empower and enable family/carers.
Clinical caseload will encompass a continuum of care for older persons extending from their well-being health needs through to the acute and chronic illnesses as they are manifested in later life.
He/she will work as part of the ICT to implement a model of care with the outcome of ensuring older persons are assessed promptly in acute or community care and supported in accessing an appropriate care pathway.
To facilitate patients and families understanding their care and to work in partnership with the community and hospital MDTs and wider communities to ensure a home first approach.
To provide a seamless integrated service with multidimensional and multidisciplinary input for older persons as they transition through the continuum of care.
Informal Enquiries
We welcome enquiries about the role.
Contact Finola Cronin Operational Team Lead ICPOP for further information about the role:
Email: f
Tel:
Contact Meagan McGlynn People Resourcing for enquiries relating to the recruitment process:
Please ensure you download save and read the Job Specification as well the Applicant Information Document. These documents are located at the bottom of this Rezoomo advertisement. We strongly recommend that you read the Job Specification associated with this post before completing your application.
Required Experience:
IC
Employment Type : Full-Time
Experience: years
Vacancy: 1