Identifying and optimising the care of respiratory patients in Oxfordshire: developing an enhanced integrated multidisciplinary team

Overview

Through joint working, Oxfordshire Clinical Commissioning Group (OCCG) and Boehringer Ingelheim (BI) piloted an enhanced NHS multidisciplinary integrated respiratory team (IRT) aimed at:

1. improving accurate, timely respiratory disease diagnosis
2. optimising clinical management
3. enhancing holistic and end-of-life care
4. identifying patients at risk of respiratory admissions and
5. integrating patient care across primary, secondary care and community settings.

The integrated team in North and City localities enhanced existing community, hospital-based and primary care by providing a community consultant working alongside additional respiratory nurses and physiotherapists, a dedicated psychologist, pharmacist, public health smoke-free advisers and specialists in palliative care. Awareness and links to third sector organisations, including Better Housing Better Health, were also improved.

This led to timely, coordinated care closer to home for respiratory patients, development of a proactive and preventative approach that showed potential to reduce system costs and resulted in positive individual patient outcomes.