Respiratory Copd Outreach

Description:

The role of the COPD Outreach team will differ according to the needs and configuration of established respiratory services at each site. The successful candidate will lead COPD Outreach and integrate this service with ambulatory care between the hospital and community services. They will work with colleagues across these services to develop and implement ambulatory care pathways and to manage respiratory disease, and associated co-morbidities, within the community setting, where appropriate. The
post holder will develop COPD Outreach services in line with the National Clinical Programme Respiratory Model of Care documents and associated guidance.
The person appointed to this post will work in the COPD Outreach Service within the assigned hospital and will be closely aligned with the associated integrated respiratory services. COPD Outreach is a four pronged service offering early supported discharge, assisted discharge, and admission prevention and case management to COPD patients. The post holder will work as part of a multidisciplinary team delivering coordinated evidence based care for patients with COPD.
The role of the CNS Respiratory in COPD Outreach is to provide initial post discharge, person centred care and on-going management of patients with COPD in the home/normal place of residence. The post holder will be a key member of the multidisciplinary team, required to provide a specialist nursing resource within the governance structure created for the programme. They will provide physical, psychological and emotional support to an agreed caseload of COPD Outreach patients and their families throughout their COPD trajectory.
In order to ensure continuity of service to patients the CNS may be required to rotate/cover other parts of the integrated respiratory service such as Respiratory Integrated Care and the Acute service. This will also promote service integration and enhance skillset development. It will be dependent on identified service needs at each site. If deemed appropriate, site rotation should occur within the first 3-6 months of taking up the post. The Clinical Nurse Specialists caseload will focus initially on patients with COPD meeting the inclusion criteria for outreach.

Responsibilities:

The CNS will deliver care in line with the five core concepts of the role set out in the Framework for the Establishment of Clinical Nurse/Midwife Specialist Post, 4th ed. National Council for the Professional Development of Nursing and Midwifery (NCNM) 2008. The concepts are:

• Clinical Focus
• Patient/Client Advocate
• Education and Training
• Audit and Research
• Consultant

Whereby the CNS is required to rotate into Acute services or Respiratory Integrated Care, some aspects of their primary role under these headings may alter to include additional duties such as running clinics in the ambulatory care hub or primary care centre, oxygen assessments and nurse led spirometry clinics.