NHS Barnsley Clinical Commissioning Group (BCCG) is committed to commissioning high quality, sustainable health care which puts the people of Barnsley first. Building on work that has already taken place to bring together multi-disciplinary community services with general practice into something called Neighbourhood Teams (NT) we now wish to align specialist community respiratory services to this model.
We are procuring a new approach to providing care for adults with respiratory conditions. The new service will be known as Barnsley REspiratory Assessment and THErapy (BREATHE) in the Community - The Integrated Specialist Respiratory Team within the Neighbourhood Team Model.
The service will be a community respiratory, out of hospital based service with a main principle of seeing and treating patients in the community, supporting them to stay well at home. The principle of self-care and health coaching should run throughout delivery.
The service will provide nursing and therapy support, specialist input to the Neighbourhood Team Model, advice and guidance, an Exacerbation Support Service (including early supported discharge), home oxygen provision and a Nebuliser Assessment Service (in patient's homes) for patients with:
- LRTI (Lower Respiratory Tract Infection)
- Respiratory rehabilitation pathways (this includes rehabilitation for all COVID19 patients)
- Cancer - End of Life
- Chronic respiratory conditions
Exclusions: Heart Failure; Acute Chest infections; and Pulmonary Rehabilitation which are commissioned independently.
The service will support admission avoidance and support people to stay well at home by implementing the following key principles:
- Integrated and working within the Barnsley Single Point of Access (SPA), Primary Care Network (PCN) and 6 Neighbourhood Teams (NT), the specialist service will use risk stratification for case management and management of patients within the NT delivery approach.
- The service will apply the NT response times or 'clock-speeds', delivering timely care and interoperability with clinical and referral systems used in Barnsley.
- Clinically led by a respiratory consultant and specialist nurse who offer expert input, and support timely advice and guidance to patients and colleagues across the Barnsley healthcare system via the SPA.
- Supporting patients to self-manage their conditions with motivation and health coaching. Clear pathways of escalation / de-escalation and communication in place.
- Providing neighbourhood based specialist consultant clinics to manage complex patients and providing specialist nurse led clinics based in each 6 NT areas - with prescribing capacity to meet patient demands
- Providing support to Discharge to Assess pathways.
- Providing end of life and palliative care including working with the local Hospice.
- Innovative staff who maximise care navigation and who are ARTP accredited to deliver and interpret spirometry.;