Referral

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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 via the Community Rehabilitation Teams (see referral instructions below for further information)

  • Aims to actively identify patients who may benefit from respiratory nurse and /or Respiratory Physiotherapist intervention at home.
  • 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 medicines review
  • To review and maximise inhaler therapy including inhaler technique
  • To assess the need for Nebulisers, provide, and educate patients and carers in their use
  • Educate patients, and their carers, about their condition and medication, and how best to self-manage their condition
  • To support patients and carers to prevent unnecessary GP and Ambulance calls
  • To support patients and carers to prevent unnecessary hospital admissions by early and rapid intervention during acute exacerbation
  • To collaborate with secondary care to facilitate early supported discharge from hospital and to provide support with weaning of medications
  • To provide assessment of, treatment of and self management plans for secretion clearance
  • Provide an accessible Pulmonary Rehabilitation service
  • Provide a home exercise programme for housebound patients
  • Is based at:
    • Cumberland Centre, Damerel Close, Plymouth, PL1 4JZ
    • Telephone: 01752 434342
    • Email: livewell.communityrespiratoryteam@nhs.net
    • Hours of work: 9:00am to 5.00pm Monday to Friday
    • Duty nurse Service available 09:00am to 5:00pm Saturday and Sunday.
    • Answer phone message service available out of hours
    • Service Manager: Kirsty Settle Tel: 01752 434342
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Referral Criteria

Patients with COPD, Bronchiectasis and ILD who are registered with a Plymouth GP

Early Supported Discharge
  • Patients who are still unwell but are safe to be discharged from Hospital with a medical management plan.
  • Agreed by Consultant or Registrar
  • Available 7 days a week, Patients discharged before 2pm may be seen the same day. Patients discharged after 2pm seen the next day.
Community Respiratory Service
  • Patients requiring advice on self-management and optimisation of therapy
  • Acute exacerbations where it is felt the intervention of the community respiratory service would prevent admission to hospital
  • Post hospital discharge needing more than GP/Practice Nurse follow-up
  • Physiotherapy for secretion clearance
  • Frequent admissions to hospital with respiratory issues
  • Patients who have frequently called 999 due to respiratory condition
  • Housebound patients that make frequent calls to GP about their respiratory condition
Pulmonary Rehabilitation
  • People with Chronic Lung Disease with breathlessness affecting their everyday life
  • Cardiovascularly stable
  • Motivated to engage in Exercise and Education sessions
  • Able to travel to community locations

This is run a as an opt-in service- patients are sent a letter following referral asking them to make contact to arrange an assessment

Home Exercise Programmes can be provided by Physiotherapists for patients who are unable to travel to community locations.

Referral
Early Supported Discharge

Telephone 01752 434342 to discuss with Duty Nurse.

Following a discussion with the duty nurse complete the referral form and email to livewell.communityrespiratoryteam@nhs.net

Or via Sentinel

Or via SystmOne – (Green star)

Respiratory referral form

Community Respiratory service including Physiotherapy and Home Exercise Programme

Complete form and email to livewell.communityrespiratoryteam@nhs.net

Or via Sentinel

Or via SystmOne – (Green star)

Respiratory referral form

Pulmonary Rehabilitation

Complete form and email to livewell.communityrespiratoryteam@nhs.net

Or via Sentinel

Or via SystmOne – (Green star)

Pulmonary Rehab referral form

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

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

Referral Forms

Pulmonary Rehab referral form

Respiratory referral form

GP Information

Patient Information

Pathway Group

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

Publication date: February 2016

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