Community Pulmonary Rehabilitation, Home Oxygen Assessment and Specialist Nurse Support Service

The overall aim of the Hounslow integrated consultant led community Pulmonary rehabilitation, home oxygen assessment and specialist nurse support service is to provide all eligible patients with a service that meets their needs and achieves the outcomes.

The objectives of the service are to:

1. Provide an integrated care service where the Provider will work with other services/stakeholders, to ensure continuity of care is provided to the patients with chronic respiratory conditions, e.g. Chronic Obstructive Pulmonary Disease (COPD)

2. Ensure pulmonary rehabilitation is accessible to all individuals with chronic respiratory conditions e.g. COPD

3. Provide a systematic and integrated assessment and review of patients on home oxygen (HOS AR)

4. Provide recently discharged COPD patients with support so that they can self-manage their condition and avoid re-admission

5. Reduce non-elective admission to hospital for those patients with diagnosed COPD, i.e.

a. Through advising primary care (General Practices) on the early identification of deterioration at primary care level

b. Following-up identified discharged patients to promote health and improve self-management, and

c. By facilitating referral into Pulmonary Rehabilitation, oxygen services and other related services as appropriate.

d. By proactively identifying the COPD patients either via SystmOne (S1) search or using WSIC dashboard and offering support to manage any exacerbation

6. Empower patients and carers to self-manage their condition and make informed choices through improving their knowledge and education provision as required

7. Provide a chest physiotherapy service for patients with chronic respiratory conditions

8. Provide a service to patients over 18 years of age and registered with Hounslow GPs