Barnet Respiratory COPD Service

Transcription

1 Barnet Respiratory COPD Service Bunmi Adebajo Clinical & Operational Service Lead Clinical Specialist Respiratory Physiotherapist Central London Healthcare NHS Trust Your healthcare closer to home Services provided by Central London Community Healthcare NHS Trust 1

2 Service context Commissioned June 2011 by Barnet CCG to deliver a COPD service with a high level of respiratory specialism in a community setting. Tasked with: Providing high quality safe care with easy access to services. Equitable and fair access in management of the patients Delivering a good patient and carer experience Responsive and patient-centred care Contain costs

3 The CLCH environment 3

4 Barnet 4

5 Barnet COPD Service Remit The overall aim of the Service is to improve the quality of patient care, for those living with COPD such as the management of complex COPD patients, and patients in receipt of home oxygen, in a setting close to, or within their homes. The Service also offers advice and education regarding COPD to primary care clinicians. COPD is characterised by progressive airflow obstruction. Airflow obstruction is defined as a reduced FEV1 as measured by spirometry when less than 80% predicted and FEV1/FVC is less than 0.7 (NICE) 5

6 Barnet COPD Service Remit This Service is part of an integrated COPD pathway across primary and secondary care, working in partnership with GPs, Respiratory Consultants, Specialist Nurses and Physiotherapists, Community Nursing and other Health Care Professionals, in order to deliver community-based care. Services provided : Assessment and management of acute exacerbations; Assessment and follow up of patients in receipt of home oxygen; Time limited case management; Community clinics; Pulmonary rehabilitation and maintenance programme; Patient support for self management; Education and support in primary care. 6

7 Barnet COPD Service Remit Pulmonary Rehabilitation MRC dyspnoea2, 3 &4 Referrals Contact Details Tel No: Fax No: BarnetCOPD@nhs.net Patient Advice Line Tel No: Barnet Community COPD Service COPD Community Clinics Home Oxygen Assessment & Follow-up (Adults all conditions) (SaO 2 <92%) Hospital at Home COPD exacerbations Respiratory Consultant Review Respiratory Nurse Specialist Review Acute Exacerbation Rapid Access Assessment & Treatment

8 The team Bunmi Adebajo Clinical & operational service lead Temi Magbagbeola Lead Respiratory Specialist Nurse Kola Akinlabi Lead Respiratory physiotherapist clinical specialist Maureen Greenwood Kim Tinneny Service administrators Sheila Morris Geraldine Kerr Tsitsi Mazivanhanga Philani Myenyiwa Senior Respiratory Nurses Annette Glencross Michelle Banks Christy Wabara Respiratory Nurses Binny Patel Ken Johnston Senior respiratory physiotherapists Rado Trojak Physiotherapy assistant 8

9 Barnet COPD Referral Pathway Community COPD Clinic Referral A&E (Not Admitted) Self (If Known to Service) GP COPD Team Community Clinic Referral for sent to: Fax: Triage by Senior Clinician Allocate to Clinic: Location, Date, Type, (Consultant, nurse, HV) (Document in referral book) Not Accepted Direct Referrals Inform referrer RMS Referrals Return to RMS Admin books patient on SystmOne & sends appointment letter to patient Patient seen in clinic by clinician GP letter & Outcome out onto clinic list Follow up & Referrals Admin Outcomes patient on SystmOne & type letters and send to GP once signed by clinician Admin puts clinic FU appointment on SystmOne & sends letter to patient Community COPD Clinic Clinic Home Visit Home O 2 Follow-up Pulmonary Rehab Dietician Social Services Case Management Palliative Care

10 Out patient community respiratory Clinics Respiratory consultant clinics Nursing & Allied Health professional clinics Edgware & Finchley Memorial hospitals New patients & follow up reviews 10

11 Domiciliary home visits & home service Domiciliary visits for IECOPD & routine planned care Nursing & physiotherapy professionals Patient advice line support Patient self referral* alongside health care professional referral

12 COPD Exacerbation Pathway Confirm COPD Exacerbation Worsening of symptoms with increased breathlessness, increased sputum, purulent sputum First Visit Assessment History taking & physical assessment Exclude other respiratory differential diagnosis Observation: SpO2, Pulse, BP, RR, Temp Baseline BORG, CAT, and HAD Investigation Initial Assessment to determine further investigations (if any) CXR ABG s CRP FBC Sputu m Implementation of COPD Treatment Plan (Normally maximum of 5 visits in 14 days is required) ECG Medication Monitoring Treatment

13 Pulmonary Rehabilitation Service Three locations within the borough Rolling programme all year round Physiotherapy lead multidiscipline delivery Programme run as seven weeks of exercise rehabilitation & education 13

14 Spirometry Delivered at Edgware & Finchley Memorial hospital Weekly delivery Currently commissioned for testing only and limited annual caseload GP referral.

15 Barnet HOS-AR Home oxygen assessment review service

16 Barnet Community COPD Service Referral Form

17 Service contact details (preferred referral route). home referrals must have a telephone call made at time of referral. Post: Barnet Respiratory COPD Office, 2 nd Floor Westgate House, Edgware Community Hospital, Burnt Oak Broadway, HA8 0AD Office Land line: Service E-Fax No: Patient Advice Line No:

18 The future 18

19 Questions 19