Community Respiratory (CORE) Team

Community Respiratory (CORE) Team

Main Address

The COmmunity REspiratory (CORE) Team comprises of integrated respiratory consultants, specialist nurses, specialist physiotherapists, smoking cessation advisors and psychology focusing on patients with chronic respiratory disease e.g. those with Chronic Obstructive Pulmonary Disease such as COPD and Bronchiectasis.  You must be registered with an Islington or Haringey GP to be referred to this service.
 
The aim of the service is to offer specialist support, education, co-ordination of care and treatment to optimise the quality of life for these individuals and their carers’. Enabling the patient & carer improve their coping strategies and their ability to self-manage their respiratory condition.
 
Services provided by the CORE Team as a result of COVID-19
 
The CORE team is now offering a range of interventions to meet the needs of people who have had COVID-19. Following a referral from your GP or other appropriate health professional you will be offered an initial phone or video assessment. If suitable you can be offered at least one face-to-face appointment at a clinic, or for those who are house bound, a home visit. 
 
In terms of support, an education programme will be offered for you or a family member or other advocate to help you better understand your condition and to help you manage your symptoms. Education material will be provided either as a booklet or as an app (MyCOPD) with follow up support via phone or video consultation. Home visits can be arranged where necessary.
 
The CORE Team works in partnership with the Trust, GPs and patients in the boroughs of Islington and Haringey to:
 
  • Prevent the burden of acute exacerbations of COPD through pro-active education and subsequent self-management
  • To identify exacerbations early and initiate treatment
  • To reduce inappropriate Emergency Department Attendances
  • To support appropriate Hospital Admissions
  • To provide in reach into hospitals and support early discharge
  • On-going  medication review and optimisation including correct inhaler technique
  • To work with patients to provide access to other community services to enable them to manage their condition better

Criteria for Inclusion into CORE team
 
  • Registered with a GP in Islington or Haringey
  • Housebound ( If not housebound consider a referral to Pulmonary Rehabilitation)
  • Have a primary chronic diagnosis of moderate to severe COPD or Bronchiectasis
  • May have asthma as secondary diagnosis but not as primary diagnosis
  • May have co-morbidities but respiratory must be primary diagnosis and co-morbidities must be stable
  • May be 1st admission to hospital with priority given to those with late / new diagnosis as above and FEV1 < 1 litre or 2nd admission with FEV1 > 1 litre
  • Two exacerbations within 12 months
  • MRC 3 or above-link  MRC Breathless scale here
  • Have stable or improving medical status when referred
  • Must have MMSE of at least 24 (to be completed by referrer on all pts. of 65 years or over or where there are concerns about cognition) or must have a carer who the team can educate in self-management
  • Patient must agree to the programme and have a desire to improve their self-management ability
  • Must have a telephone or have a nominated carer so there are able to utilise the CORE team
  • Where chronic anxiety is a dominant factor this should be addressed prior to referral to CORE.

Criteria for Exclusion from CORE service
 
Patients should NOT be referred to the CORE service if: 
  • Primary diagnosis not COPD, Bronchiectasis, Pulmonary Fibrosis or Type 2 Respiratory failure
  • Where asthma is the primary diagnosis
  • Diagnostic uncertainty
  • General medical condition not stable at time of referral
  • Patient confused at time of assessment
  • History of being unable to co-operate with advice given
  • Does not agree to home care
  • Previous evidence of failure to respond to our service (assessed on an individual basis)
  • Patient has no phone at home
  • No recent spirometry, height and weight recorded

Further Criteria for Exclusion from CORE service
 
  • History of being unable to co-operate with advice given
  • Previous evidence of failure to respond to our service
  • Untreated drug or alcohol dependencies were this may pose a risk to the visiting HCP. This also includes physical violence and verbal abuse- This can be discussed with the team

Appointments

Central Booking Service: 020 3316 1111

Useful resources

Monday - Friday (excluding bank holidays)
9am - 5pm
Islington GP email referral form to:

Haringey GP email referral form to:
 
Please discuss referrals with CORE team by phoning 0207 288 5474.
Last updated30 Jun 2021
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