Your healthcare closer to home

Services provided by Central London Community Healthcare NHS Trust

www.clch.nhs.uk

Barnet Respiratory COPD

Service

Bunmi Adebajo

Clinical & Operational Service Lead

Clinical Specialist Respiratory Physiotherapist

Central London Healthcare NHS Trust

1

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

The CLCH environment

3

Barnet

4

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

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

Barnet COPD Service Remit

Contact Details

Tel No: 02083497539

Fax No: 0300 0083159

E-mail: BarnetCOPD@nhs.net

Patient Advice Line Tel No:

07943828371

Respiratory

Consultant

Review

Acute

Exacerbation

Rapid Access Assessment &

Treatment

Respiratory

Nurse Specialist

Review

Hospital at HomeCOPD exacerbations

Pulmonary

RehabilitationMRC dyspnoea2, 3 &4

Home Oxygen

Assessment &

Follow-up (Adults all

conditions)

(SaO2 <92%)

COPD

Community

ClinicsReferrals

BarnetCommunity COPD Service

The team

8

Bunmi Adebajo

Clinical & operational service lead

Temi Magbagbeola

Lead Respiratory Specialist Nurse

Sheila Morris

Geraldine Kerr

Tsitsi Mazivanhanga

Philani Myenyiwa

Senior Respiratory Nurses

Annette Glencross

Michelle Banks

Christy Wabara

Respiratory Nurses

Kola Akinlabi

Lead Respiratory physiotherapist clinical specialist

Binny Patel

Ken Johnston

Senior respiratory physiotherapists

Rado Trojak

Physiotherapy assistant

Maureen Greenwood

Kim Tinneny

Service administrators

GP COPD Team Community

ClinicReferral for sent to:Fax: 0208 349 7353

E-mail: BarnetCOPD@NHS.net

Triage by Senior

Clinician

Not Accepted

Direct ReferralsInform referrer

RMS ReferralsReturn to RMSAllocate to Clinic:

Location, Date, Type, (Consultant, nurse, HV)(Document in referral book)

Admin books patient on SystmOne & sends

appointment letter to patient

Patient seen in clinic by clinician

GP letter & Outcome out onto clinic list

Community COPD Clinic

Clinic Home Visit

Social Services

Home O2

Follow-upDietician Palliative

CarePulmonary

RehabCase

Management

Self (If Known to Service)

A&E(Not Admitted)

Referral

Community COPD Clinic

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

Barnet COPD Referral Pathway

Out patient community

respiratory Clinics• Respiratory

consultant clinics

• Nursing & Allied

Health professional

clinics

• Edgware & Finchley

Memorial hospitals

• New patients & follow

up reviews

10

Domiciliary home visits & Hospital @ home service

Domiciliary visits for

IECOPD & routine

planned care

Nursing & physiotherapy

professionals

Patient advice line

support

Patient self referral*

alongside health care

professional referral

CRP FBC Sputu

m

ECG

Initial Assessment to determine further investigations (if any)

Monitoring

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

ABG’sCXR

Implementation of COPD Treatment Plan

(Normally maximum of 5 visits in 14 days is required)

Medication Treatment

COPD Exacerbation Pathway

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

Spirometry

• Delivered at Edgware

& Finchley Memorial

hospital

• Weekly delivery

• Currently

commissioned for

testing only and

limited annual

caseload

• GP referral.

Barnet HOS-ARHome oxygen assessment review service

Barnet Community COPD Service Referral Form

Service contact details

• E-mail: BarnetCOPD@nhs.net (preferred referral

route). Hospital @ home referrals must have a

telephone call made at time of referral.

• Post: Barnet Respiratory COPD Office, 2nd Floor

Westgate House, Edgware Community Hospital, Burnt

Oak Broadway, HA8 0AD

• Office Land line: 02083497539

• Service E-Fax No: 0300 0083159

• Patient Advice Line No: 0794382837117

The future

18

Questions

19