Community Respiratory (CORE) Team

Islington
Add to CPD

The integrated COPD service is a consultant led multi-disciplinary team providing care to patients with complex respiratory conditions in the community. The service works with patients and their careers to improve the quality of life and patient experience for those living with COPD and frightening disabling breathlessness.

This is achieved by providing a seamless and integrated COPD pathway where focus is placed on patient education, supporting the treatment of tobacco dependence, referring to appropriate services such as pulmonary rehabilitation and supporting self-management. Together with the patient, an individualised care plan is put together and patients are encouraged to contact the team if any deterioration in their symptoms.

Consider referral for patients:

  • with frequent exacerbations (>/= two per year)
  • who over use inhaled therapy
  • with a need for multiple courses of steroids
  • with a worsening symptom profile
  • who may benefit from better disease education and support to develop self-management skills
  • who have had a recent hospital admission.

Another service provided by the team is the Acute Exacerbation of COPD (AECOPD) pathway, where patients who are having an exacerbation can be supported in their home. 

Patients are either assessed in the community clinic or in their own homes by a member of the CORE team. All patients are discussed in a consultant-led multidisciplinary team meeting and the outcome is communicated to the primary care clinician.

All discharged patients will, we hope, have a good understanding of self-management, with appropriate education and lifestyle/risk modification. There is an open route of either self-referral or via healthcare professionals back into the service as needs arise.

Patients are discharged:

  • when their episode of care is completed
  • if they fail to engage with the service
  • if they move out of the area.
  • if COPD is no longer the primary health problem
  • if it is felt, the team is in danger of harm or abuse from the patient, carer or environment.

Integrated Consultants can be contacted for advice, Mon-Fri 10am-5pm, as follows:

UCLH
Respiratory Specialist Nurse
t: 07887 7879 59
e: uclh.respiratorynurses@nhs.net

Dr Melissa Heightman
t: 07825 291 451

Whittington Health
Dr Melissa Heightman
e: Melissa.heightman1@nhs.net (email preferred)
t: 07768 728 992

Dr Ruvini Dharmagunawardena
e: ruvini.dharmagunawardena@nhs.net (email preferred)
t: 07768 728 992


Eligibility criteria

Inclusions

  • age 18+
  • registered with an Islington GP
  • COPD primary diagnosis, confirmed with spirometry
  • patients must have a current working contact number

Exclusions

  • unconfirmed diagnosis
  • unstable co-morbidities that may be causing/mostly contributing to current deterioration
  • rapidly worsening symptoms that require urgent care intervention
  • cognitive impairment that would affect ability to work with the team, unless living with a carer who can support the management of patient’s condition

How to refer

The following clinicians can refer to this service: GPs, Nurses

EMIS form

Referral methods: Email

A referral form can be found in ISL EMIS under
ISL global documents > LTC  > Long term conditions community service referral (select COPD)

e: articentralbookings@nhs.net


Locations