A consultant-supported multi-disciplinary team, providing domiciliary visits to housebound patients with severe respiratory disease, who frequently have exacerbations or hospital admissions.

The team also provides:

• exacerbation management in previously known patients
• support on hospital discharge
• medication optimisation and medication trials
• individualised self-management plans e.g. home pulmonary rehabilitation (with a view to attending class-based PR) breathlessness management, psychology input, disease 
• disease and exacerbation education

The team attend weekly meetings with respiratory consultants from UCLH and RFH to discuss referrals. An MDT care plan will be sent to the referring GP.

Eligibility Criteria

Inclusions

• housebound patients with confirmed diagnosis of COPD
• and/or frequent exacerbations or hospital admissions

Exclusions

• Patients that can attend a respiratory clinic will be offered all the above in an out-patient setting
• Patients without a COPD diagnosis

How to Refer