1. Community Respiratory Specialist Service
West Essex

2. Respiratory Nurse Specialist & Team Leader
Linda Barr
Respiratory Nurse Specialist & Team Leader

3. Service Overview COPD Interstitial Lung disease Bronchiectasis Asthma
We are a Community Respiratory Specialist Team who provides care for adult respiratory patients who are registered with a West Essex GP

4. Service objectives
To support patients and carers to navigate the health and care system and make best use of resources available
To identify and support people early enough to make a difference
To ensure the right people get the support at the right time.
To make access to service clear and simple

5. Where is the service provided
Patients’ homes
Various Clinics Within West Essex
Pulmonary rehabilitation gyms across West Essex

6. Who can refer Self-referrals (if known to the team)
GPs and Practice Nurses
Secondary Care
MDT
Care homes / Social care
Community nurses and allied health professionals

7. What We Provide
Oxygen Management and Assessment of respiratory patients – working with CCG to ensure safe prescribing and giving cost effective modalities without compromising patients quality of life.
Exacerbation Management – timely intervention and hospital prevention
Management plans to reduce hospital admissions and improve quality of life
MyCOPD -access to education and exercise programme in own home
Working closely with wider community practitioners, including GPs community staff, care homes, local hospice, BreathEasy
Working closely with secondary care MDT’s, intergrated, respiratory nurses
Support for respiratory palliative care, District nurses, Palliative Care Nurses

8. What Else Do We Provide? Respiratory related breathlessness management
Teaching and Education
48 hour response for urgent patients
Supportive discharge - for patients who are on the COPD Discharge Bundle
Patient contact within 5 working days for non-urgent referrals

9. Who Are Your Nurses Harlow PCN’s
Linda Barr -Team Leader Respiratory Nurse Specialist & Nurse prescriber
Jill Flintham – Snr Respiratory Assistant.
Epping PCN’s
David Gibson –Respiratory Nurse Specialist -undertaking his prescribing course
Kate Spillane – Snr Respiratory Assistant – new to post,
Uttlesford PCN’s Irene England –Respiratory Nurse Specialist &Nurse Prescriber Carole Rolland – Respiratory Nurse Specialist Most of these nurses have a 10 yr+ history with the team delivering consistent respiratory care to West Essex

10. Who Are Your Therapy Team?
Sally Wood – Lead Specialist Respiratory Physiotherapist for Pulmonary Rehabilitation & Chest Physio
Kirsty Jones – Snr Pulmonary Rehabilitation Support Worker

11. Pulmonary Rehabilitation
Sally Wood – Lead Physiotherapist Pulmonary Rehabilitation & Chest Physio

12. What is Pulmonary Rehabilitation?
Therapy Led
Group exercise and education programme
2 sessions per week for 6 weeks
Up to 16 patients per group
Warm up –> Circuit training -> Education
1 of the 9 interventions for patients with COPD/Respiratory Diagnosis
Available to patients from Gold Classification B->D and MRC3+

13. Why refer to Pulmonary Rehabilitation?

14. Barriers Patient disinterest Negative feedback from friends/family
Lack of knowledge about Pulmonary Rehabilitation
Lack of understanding about benefits of Pulmonary Rehabilitation
Incorrect knowledge of current criteria of referral
Previously attended
Feels too unwell/breathless
Decreased mobility/function
Transport issues
Currently only half of eligible patients are referred for Pulmonary Rehabilitation in West Essex
We need to do more to promote the service
Referrals have grown by 45% 17/18 and 8% 19/20% - but there are still a lot of people who would benefit
Referral offered will be part of QOF and is within your current LES and 9 high care interventions

15. Facilitators -How can we get patients to engage?
Patients should be educated that it is part of their total holistic care – it is not an add on!
A step wise management plan should be agreed with pulmonary rehabilitation as one of the steps before considering adding in more inhalers/medication therapy
Use video clips with your patients to show them what it is and what it entails
Make sure you and they know the benefits to their health
Refer even if mobility/transport problems – alternatives can be found, education can be given by exercise specialists

16. So far we have…..
Changed our referral criteria to include patients with a variety of respiratory conditions i.e. Asthma, Bronchiectasis and Interstitial Lung Disease (ILD)
Opened up referral to GOLD Cat B COPD patients
Progressively increased group size 12 -> 16
Changed from cohort to rolling groups

17. The Next Steps Continue to review our referral processes
Continue to review our waiting times – currently average of 7-8 weeks
Provide patients an opportunity to come and ‘observe’ a session prior to accepting a place on the course – patients and HCP
Opportunity for patients to complete PR exercises at home (unsupervised)
Consider alternative referral - chest physiotherapy
Continue to actively promote PR within the PCN’s – we need referrals to grow the service

18. Video

19. Primary Care Networks Vanessa Wakefield – Service Manager Respiratory & Cardiac Services
Where do we fit in?
How can we support you?

20. Named Specialist Nurse
Each PCN will have a named respiratory specialist nurse assigned to them
They will be your first point of contact Mobile Phone / access
Aim to support you with correct diagnosis, treatment plans, specialist advice and supportive input for your patients
Support with completing the 9 High Care Intervention

21. Who Should You Being Referring?
Risk Stratification & Staging
Management A 
Low Risk / Low Symptoms
Managed in Primary Care B 
Low Risk / High Symptoms
Co-managed in Primary Care
Referral through the Single Point of Access (SPA) to Community Respiratory Specialist Team for assessment for:
Pulmonary Rehabilitation
Home  or clinic visits from Community Specialist Nursing Team
Urgent referrals will be seen by EPUT within 2 working days   C
High Risk / Low Symptoms
Initial Support Review for Early COPD (Training to be provided by EPUT
Referral through SPA to Community Respiratory Specialist Team for assessment for:
•             MyCOPD
•             Pulmonary Rehabilitation
•             Home or clinic visits  from Community Specialist Nursing Team
Urgent referrals will be seen by EPUT within 2 working days  Or clinic appointment D 
High Risk / High Symptoms
Referral to Secondary Specialist Care  for diagnostic accuracy, assessment and treatment
MyCOPD
Exacerbation prevention
Home visits from Community Specialist Nursing Team
Assessment for oxygen therapy
Urgent referrals will be seen by EPUT within 2 working days.

22. What Should Be Considered?
Are they palliative/EOL?– do they require specialist respiratory nursing/physio support? i.e.PalliatiaveCare Nurses/Community Nurses/Hospice
Do they require an Oxygen assessment ?
Would they benefit from using MYCOPD? - a supportive self management tool
Would they benefit from Healthy Minds input? – current joint initiative between EPUT & Healthy Minds team specifically tailored to patients with respiratory disease
Have they been referred for Community Respiratory Specialist Nursing input (B,C&D GOLD classification, repeated A&E attendance, NEL’s) ?
Have they been referred for Pulmonary Rehabilitation?
Patients

23. Specialist MDT’s
Community Respiratory lead for PCN’s will attend these meetings
Support practices with reviewing registers/searches /9 high care interventions
Discuss Case Studies/Management plans & Signposting
Facilitate improved inter-professional relationships and joint working
Improved co-ordination of care
Identification of any staff training needs and provision of education

24. Integrated Care?

25. Questions