Community Respiratory Specialist Service West Essex

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

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

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

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

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

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

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

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

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

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

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+

Why refer to Pulmonary Rehabilitation?

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

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

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

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

Video https://youtu.be/LLfuM1094QY

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

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 /email 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

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.

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

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

Integrated Care?

Questions