How Integrated is Our Integrated Care? Exploring Concepts and Contexts in the Care for Older Persons During Discharge in Ireland

Abstract

Background: Across Ireland, older people often experience fragmented care when discharged from hospital to home or community settings. Although integrated care aims to ensure a smooth, coordinated transition, its implementation frequently falls short of expectations. The consequences include delayed discharges, hospital overcrowding, and adverse outcomes such as medication errors and readmissions. As the population ages and multimorbidity rises, the need for well-coordinated, person-centred discharge planning has become more urgent.   Approach: This paper provides a critical discussion of integrated care within the Irish context, particularly as it relates to the discharge process for older persons. Drawing on national and international literature, as well as policy frameworks such as Sláintecare and the Integrated Care Programme for Older Persons (ICPOP), the discussion explores the conceptual underpinnings of integrated care and how it operates in practice. The paper analyses the roles of key stakeholders—including nurses, patients, families, and multidisciplinary teams—and examines systemic and contextual barriers that limit effective care integration. It also reflects on opportunities for innovation, particularly the use of digital health technologies and nurse-led interventions.   Results: The discussion highlights that, despite strong policy frameworks, integrated care remains inconsistently applied across Irish healthcare settings. Persistent barriers include limited communication between hospital and community services, inadequate staffing, and underdeveloped digital health systems. Nurses, who play a pivotal role in facilitating discharge and continuity of care, often navigate complex systems without adequate support or resources. Nonetheless, examples of good practice exist—nurse-led discharge planning, collaborative team approaches, and the adoption of electronic health records have been shown to enhance patient satisfaction, reduce readmissions, and improve communication between providers. These examples illustrate that integrated care can be achieved when supported by clear protocols, interdisciplinary collaboration, and active patient and family engagement.     Implications: For practice, the paper emphasizes the need to strengthen the role of nurses as coordinators of care transitions, supported by adequate training and resources. Policymakers should prioritize investment in community-based services and digital health infrastructure to facilitate information sharing and improve care continuity. Nursing education should integrate concepts of care coordination, interdisciplinary teamwork, and person-centred discharge planning into curricula.   For research, further exploration is needed on the impact of nurse-led discharge interventions and technology-enabled integration on patient outcomes and system efficiency. For international delegates, Ireland’s experience underscores a universal challenge—bridging the gap between the theory and reality of integrated care. The Irish context offers transferable insights into achieving sustainable, person-centred systems where interdisciplinary collaboration, digital transformation, and community capacity-building can collectively improve outcomes for older persons globally. References available