REMOTE PULMONARY REHABILITATION A Model for Delivery Jane Dernie September 2010

Standard 4: Pulmonary rehabilitation Standard statement 4a Pulmonary rehabilitation is available within the NHS board to people with COPD who have an MRC dyspnoea scale score of 3 or more. Rationale Pulmonary rehabilitation delivered by a multidisciplinary team can improve the health-related quality of life, exercise capacity and breathlessness of people with COPD. There is good evidence to support the benefits of pulmonary rehabilitation post-exacerbation. Pulmonary rehabilitation has been shown to be an effective treatment for people with COPD. References: 4, 9, 10 Essential criteria 4a.1 Pulmonary rehabilitation is offered to people with COPD with an MRC dyspnoea scale score of 3 or more. 4a.2 Pulmonary rehabilitation is accessible to qualifying people with COPD. 4a.3 Pulmonary rehabilitation incorporates: • upper and lower body physical training, and • disease education including smoking cessation. 4a.4 - Pulmonary rehabilitation is available for people with COPD post exacerbation. Desirable criteria 4a.5 Pulmonary rehabilitation incorporates: • medication management • nutritional intervention • psychological and behavioural interventions, and • occupational therapy.

Running class at central PRI site with present staffing Delivering class via Tanberg 880s Codec camera with 28 inch monitor to Pitlochry Community Hospital Physiotherapy Assistant supporting and supervising patients at Pitlochry

Programme Ran Oct – Dec 2008 12 patients assessed for PRI 10 patients completed 122 attendances 3 patients assessed for Pitlochry 2 patients completed 34 attendances Measures Reliability of Equipment Skill mix of staff Effectiveness of model Economics Satisfaction

Overview of Service Referrals to Physiotherapy

CONFIRM DIAGNOSIS OF COPD GUIDELINE FOR REFERRAL TO THE (PILOT) TELEMEDICINE PULMONARY REHABILITATION FOR COPD The principal goals of pulmonary rehabilitation are to reduce the symptoms, improve quality of life and increase physical and emotional participation in everyday activities. DRAFT CONFIRM DIAGNOSIS OF COPD YES Moderate/Severe COPD and/or MRC 3 or above NO Optimise drug therapy Smoking cessation Lifestyle advice Exercise referral scheme Refer to PRI Pulmonary Rehab Programme (if meets criteria) Optimise Drug Therapy Trial of long acting bronchodilator anticholinergic and reg B2-agonist Ex-smoker/ motivated to stop Willing to attend twice per week for 8 weeks Able to get to Pilot Centre NO YES Any Contra-indications to rehab present? Unstable angina Unable to walk independently Requires one-to-one input Musculoskeletal problem causing ongoing stiffness or pain Recent PE/DVT/MI (6 weeks) 2nd/3rd Degree heart block Resting HR > 120 Resting BP systolic > 200/diastolic >100 Dementia/Psychosis Hearing or Visual impairment (i.e. not able to follow instruction from monitor) Requiring oxygen to safely exercise MRC Dyspnoea scale Grade Degree of breathlessness related to activities Not troubled by breathlessness except on strenuous exercise Short of breath when hurrying or walking up a slight hill Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace Stops for breath after walking about 100m or after a few minutes on level ground Too breathless to leave the house, or breathless when dressing or undressing YES 1 2 NO 3 REFER TO PULMONARY REHAB Pilot Telemedicine Pulmonary Rehab Physiotherapy Dept Perth Royal Infirmary Perth PH1 1NX 4 5

Overview of Service Format: 10 weeks x twice a week (currently testing 8) 8 weeks programme: 1 week either side for assessment pre and post Content: Physical activity; graduated exercise programme Education: What is COPD Breathing Control Sputum Clearance Medication and Inhalers Nutrition * Pensions and Benefits Coping Strategies & Anxiety Breathe Easy Holidays & Travel *Energy Consumption *Equipment *Time Management *Relaxation Keeping Active OT Onward referral to Perth & Kinross Leisure Pilot of Art Therapy

Where are we now? Where do we go from here? Regular delivery to 3 outlying sites Part of National project to further roll out Testing 8 weeks programme Up-skilling of CRT’s to deliver intervention Where do we go from here? Further efficiencies required Need to expand access to incorporate exacerbations Need to look at role of community teams/virtual wards

NEW DRIVERS Health of the Population Experience of Care Per Capita QUALITY AMBITIONS TRIPLE AIM Mutually beneficial partnerships between patients, their families and those delivering healthcare services. Partnerships which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making. No avoidable injury or harm from the healthcare they receive, and that they are cared for in an appropriate, clean and safe environment at all times. The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, with no wasteful or harmful variation. Health of the Population Experience of Care Per Capita Cost

DISCUSSION