Community Respiratory Service

Scope

The Community Respiratory Service

Please note this service is only open to patients registered with a Plymouth GP practice. Pulmonary Rehabilitation services are available in Tavistock and the South Hams, see referral instuctions for information.

  • Aims to actively identify patients who may benefit from respiratory nurse/physiotherapist intervention
  • To provide and facilitate the co-ordination of individualised and holistic care for people with respiratory conditions
  • To undertake a respiratory assessment of the patient including; spirometry, pulse oximetry, chest auscultation, and in-check for correct inhaler device
  • Maximise therapy
  • Educate patients, and their carers, as to their condition and medication, and how best to manage their condition
  • Prevent unnecessary GP and ambulance calls
  • Prevent unnecessary hospital admissions by early and rapid intervention in acute exacerbations
  • To liaise with secondary care to facilitate early discharge from hospital to the community
  • Provide an accessible pulmonary rehabilitation service
  • Provide a home exercise programme for housebound patients
  • Provide chest physiotherapy
  • Provide an oxygen assessment service in conjunction with secondary care
  • Provide a nebuliser assessment service
  • Is based at:
    • Cumberland Centre, Damerel Close, Plymouth, PL1 4JZ
    • Telephone: 01752 434342
    • Fax: 01752 314627
    • Hours of work: 8.30am til 5.00pm Monday to Sunday
    • Telephone advice available Bank Holidays. (Please note no physiotherapy available weekends)
    • Answer phone message service available out of hours
    • Service Manager: Steve Pearse Tel: 01752 434342 Mobile: 07765258674
    • Email: stephenpearse@nhs.net

Management

Referral

Referral Criteria

Patients with moderate to very severe chronic obstructive pulmonary disease (COPD), poorly controlled asthma or other respiratory conditions, who are registered with a Plymouth GP, and one or more of the following apply:

  • Acute exacerbations where it is felt the intervention of the community respiratory service would prevent admission to hospital
  • Early supported discharge from hospital
  • Acute chest physiotherapy
  • Two or more hospital admissions a year with exacerbation of their respiratory condition, and not managed by GP/Practice Nurse
  • Post hospital discharge needing more than GP/Practice Nurse follow-up
  • Frequent 999 callers
  • Housebound patients that make frequent calls to GP about their respiratory condition
  • Pulmonary rehabilitation (or home exercise programme to housebound patients)
  • Advice required on management/optimising therapy
  • Oxygen assessment via the oxygen clinic
  • Nebuliser assessment for patients
  • Non concordance with therapy
  • Supporting palliative care

Referral Instructions

Urgent referrals (need to be seen within 24 hours)
  • Can be made by telephone (01752 434 342) but must be followed up by one of the methods below
  • Please provide as much information as possible at the time of the call
    • Patient details (name, address, telephone number, date of birth and NHS number (if available)
    • Medical history (past and recent)
    • Current medication (including any known adverse reactions)
    • Any observations taken
    • Any other relevant information such as any access difficulties, pets, possible dangers to lone workers (will visit in pairs if necessary)
    • We will then telephone the patient (or their carer) to let them know an estimated time of arrival
    • While we will do our best to see patients on the day of referral, we cannot guarantee to see referrals made after 14:00
    • Joint visits with the referrer can always be arranged if required
    • A letter will always be sent to the patients GP (and referrer if different) as soon as possible following a visit, outlining assessment and action taken, and any follow up planned
Routine GP referral
  • e-Referral service selection
    • Specialty: Respiratory
    • Clinic Type: Not otherwise specified
    • Service: DRSS- Western-Respiratory Medicine- NEW Devon CCG-99p
  • After the initial assessment, the patients GP (and referrer if different) will be sent a letter that will include the following:
    • Spirometry (if appropriate)
    • Oxygen saturations
    • MRC score
    • CAT score
    • BMI
    • Any other relevant observations
    • Recommendations for medication regime
    • Any other recommendations
    • Any further follow up planned
Internal Livewell Southwest referrals
  • Can be made using the background assessment form (formerly BICCA) by post or fax (01752 314 627)
Referrals from Derriford
  • Are made through the In-reach team (53859 or bleep 89173) Monday to Friday, or by sending consultant letter
  • For patients being discharged, and needing to be seen next day, please fax discharge letter (01752 314 627)
For Pulmonary Rehabilitation
  • Complete pulmonary rehabilitation form
  • Fax (01752 314627) or
  • Post to Community Respiratory Team, The Cumberland Centre, Damerel Close, Plymouth, PL1 4JZ
  • On receipt of the referral the patient is contacted by letter to see if they want to participate in the programme and a list of the venues currently on offer throughout the year

In all cases the referral will be triaged by a duty nurse, who will be available to discuss referrals. The patient will be informed that a referral has been made and arrangements made to see them (by telephone, but if unable to contact, by letter)

For Tavistock it is;
Tavistock Community Rehab Team.
DCC Offices
Abby Rise
Whitchurch Road
Tavistock PL19 9AS
Email: tavistockcommunityrehabteam@nhs.net

For Kingsbridge;
Kingsbridge Rehab Team
South Hams Hospital
Kingsbridge TQ7 1AT
Tel: 01548 855974

Referral Forms

Referral form

Supporting Information

Patient Information

Pathway Group

This guideline has been signed off by the Western Locality on behalf of NEW Devon CCG.

Publication date: 05 February 2016 (updated November 2016)

 

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