JOHN MUIR HEALTH PULMONARY REHABILITATION PROGRAM Lana Hilling, RCP, FAACVPR Coordinator, Lung Health Services John Muir Health 925-674-2351 Lana.hilling@johnmuirhealth.com

How to Refer to PR Call the PRP at 674-2351 OR Fax Physician Referral 674-2036 Required information/tests Recent H&P and office notes Complete PFT with DLCO (within past year) EKG Chest X-Ray CBC ABG, if patient already has one

COPD Statistics COPD is the 4th leading cause of death (only top killer with increasing mortality) COPD ranks second as a cause of disability 12 million+ have COPD On average only 10-15% of these eligible candidates receive Pulmonary Rehab Another 12 million may have it but don’t know it 1 out of 6 Americans with COPD has never smoked

COPD Statistics (Cont’d) COPD is responsible for more than 10 million doctor’s visits per year, 1.5 ED visits and 600,0000 hospitalizations (GOAL OF PR—Decrease hospitalizations, length of stay and ED visits) COPD cost US - total $32.1 billion Next 20 years-total ~ $832.9 billion

COPD The Coalition is working to encourage the designation of November as National COPD Awareness Month each year. The Coalition also organizes activities on World COPD Day, a partnership between health care groups and respiratory educators to raise awareness about COPD that was held for the first time on Nov. 20, 2002. Reference from the GOLD News Letter Global Initiative for Chronic Obstructive Lung Disease

Pulmonary Rehabilitation PR recognized as integral component of standard quality medical therapy Strategies, therapeutic interventions and Disease Management Principles are well established Documented benefits are substantial Expanding beyond the COPD patient to other Chronic Respiratory Conditions for patients with symptoms or reductions in functional status despite optimal medical therapy

ATS/ERS Pulmonary Rehabilitation Definition “PR is an evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities.

ATS/ERS Pulmonary Rehabilitation Definition (con’d) Integrated into the individualized treatment of the patient, PR is designed to reduce symptoms, optimize functional status, increase participation and reduce health care costs through stabilizing or reversing systemic manifestations of the disease.”

Challenges Remaining Skepticism from the medical community Lack of enthusiasm from some physicians Insufficient numbers of referrals and delays in referrals Inadequate program availability in some regions of the country CMS National Coverage Policy currently being written is unacceptable

Goals of Pulmonary Rehab Control & alleviate symptoms Improve quality of life Increase exercise tolerance Promote self-reliance & independence (ADLs) Decrease use of medical resources Individualized personal and program goals are established with each patient upon entry into the program. Pulmonary Rehab assists patients in identifying and readdressing these goals based on medical status and individual patient progress. Pulmonary Rehab is dedicated to identifying the patient’s limitations and working with each patient and his/her family toward establishing and maintaining healthy lifestyle behavior change strategies. This multifactorial process is designed to limit the adverse physiologic and psychological effects of pulmonary illness, reducing hospitalizations, and increasing the patients functional ability to improve QOL.

AACVPR

Essential Components of Pulmonary Rehabilitation Prevention And Outcomes

Interdisciplinary Team Medical Directors Dr. Richard Kops, Concord Campus Dr. Karin Cheung, Walnut Creek Campus Program Coordinator/Director Rehabilitation Specialist Patient Referring physician Respiratory Therapist Physical Therapist Dietitian Pharmacist Social Worker

10-00-11:00 Introduction & Pre-Testing 11:00-12:00 Respiratory System: DATE: Tuesday 3-13-07 WEEK 1 10-00-11:00 Introduction & Pre-Testing 11:00-12:00 Respiratory System: Structure and Function 12:00-1:30 Exercise DATE: Thursday 3-15-07 10:00-11:00 Support Group 11:00-12:00 Breathing Retraining 12:00-1:30 Exercise DATE: Tuesday 3-20-07 WEEK 2 10:00-11:00 Support Group/ Durable Power of Health Care 11:00-12:00 MDI’s DATE: Thursday 3-22-07 9:00-10:30 Dietary Evaluations Medication Consults 10:30-11:00 Medications 11:00-12:00 Self Assessment DATE: Tuesday 3-27-07 WEEK 3 10:00-11:00 Exercise Principles 11:00-12:00 Your Food Life 12:00-1:30 Exercise DATE: Thursday 3-29-07 10:00-11:00 Support Group/Stress Management 11:00-12:00 ADLs DATE: Tuesday 4-3-07 WEEK 4 10:00-11:00 Disease Process 11:00-12:00 Review/ Emergency Aids/ Home Equipment & Travel/Smoking Cessation 12:00-1:30 Exercise DATE: Thursday 4-5-07 10:00-11:00 Support Group/ Relaxation Techniques 11:00-12:00 Post-Testing 1:30 Advance Directives DATES: 4-9, 4-11, 4-13 WEEK 5 MON., WED., FRI., 11:45 – 1:00 Exercise DATES: 4-16, 4-18, 4-20 WEEK 6 MON., WED., FRI., Home Exercise Prescription

Conditions Appropriate for Pulmonary Rehabilitation Obstructive Diseases Restrictive Diseases Chest wall diseases Neuromuscular diseases Other conditions Lung cancer Primary pulmonary hypertension Pre and post thoracic and abdominal surgery Pre and post lung transplantation Pre and post lung volume reduction surgery Ventilator dependency Obesity-related respiratory disease Medicare provides reimbursement for the following diagnoses with the specific diagnosis code present.

Patient Selection Criteria Appropriate Conditions Degree of impairment in PFT commonly used PFT – FVC, FEV1, and /or DLCO < 65% (helpful but symptoms correlate better with functional ability) Reduction in physical activity, occupational performance, ADL’s and increased consumption of medical resources

Patient Selection Criteria Possible contraindications for PR Unstable Cardiac Disease Severe Pulmonary Hypertension Other concurrent diseases or conditions Use of tobacco Motivation Financial concerns Transportation problems Disease States that may require modifications Advanced liver disease Stroke Cognitive deficit and psychiatric disease

Patient Assessment Patient Interview Medical History Physical Exam Diagnostic Tests Symptoms Assessment Musculoskeletal & Exercise Assessment Nutritional Assessment Educational Assessment Psychosocial Assessment Goal Development

GOALS Goals Long-term adherence Patient goals Team goals Realistic Short & long term Emphasis on ADL’s Long-term adherence You need to work with the patient to develop short and long term goals, as the goals are necessary for you to develop your plan of care. The challenge sometimes is to translate the patient goals into measurable outcomes for assessment and documentation. The goals need to be realistic and specific. They can not be “Many patients are not aware of Medicare wants functional goals that relate to ADL’s. We review the goals with the patients the first day of class. This provides them an opportunity to add or change their goals. Then we give them a copy to put in their binder and we refer back to them at least once a week, so they are more aware if they are making progress towards their goals or if their goals have changed. This patient was trying to keep working construction when he came into the program. It was apparent to the team, that this wasn’t possible, so when we felt like he would be more open to it we discussed the feasibility of him retiring. It turned out that he was happy we brought it up, as he was already beginning to adjust to the idea that his job was too strenuous. One of his goals was to go fly fishing when he moved to Montana, and he did. I know you cannot see it in this picture, but he is wearing oxygen. Others goals are to play with their pets or take them for a walk.

Objective of Patient Education/ Training Encourage behavioral change Improved health Patients active in their health care Achieve optimal levels of understanding and self-management Commitment to long-term adherence

Education Process (Cont’d) Determine how the patient learns best Provide written materials Review patient’s goals on a regular basis Select the approach or style that benefits the patient the most

Teaching Styles (Cont’d) Treat Patients Like Adults Responsible for what they learn Clearly State Why and How information is important Link it to their daily activities Build a trusting relationship with the patients There are no stupid questions or answers

Identify Barriers to Learning

Education and Skills Training Normal A & P and the Disease Process Oxygen Rationale Activities of Daily Living Benefits of Exercise Nutrition Guidelines Smoking Cessation/hazards of secondhand smoke

Breathing Retraining

Correct Inhaler Technique

Infection Control Twinkle Twinkle Little Star

Self Assessment Techniques

Exercise Training Duration Frequency Mode Intensity Exercise Prescription Endurance training Strength training Specific techniques Upper and lower extremity exercises Posture and Body Mechanics Respiratory Muscle Training Stretching Home exercise Prescription/Maintenance Exercise

Psychosocial Component Critical to the success of PR Depressive symptoms may contribute more to functional disability, poor health perception and poor well-being than the chronic medical condition itself Support Group Learn coping skills Stress management/relaxation techniques Anger management

Psychosocial Component Ethical Issues Addressed Advanced Directives Limitation of medical intervention by paramedics Address Issues of Sexuality Refer for counseling and or medications

Long Term Adherence Personal lifestyle changes are made by a person, PR is a Commitment to a lifestyle change Short term interventions do not result in long term gains Patients must continue to participate in their exercise regimes and other adopted lifestyle changes Emphasis on relapse prevention strategies Develop a plan to promote and reinforce strategies learned Personal lifestyle changes are made by a person, not a plan.

Verona Arena, Italy

" I made it through the hills of Italy, the streets of Florence and climbed to the top of this arena. I could not have done it without your help."

Heart and Lung Games

Second International Heart and Lung Games Chicago, IL 2006

Patient Definition Pulmonary Rehabilitation has been a life-saving pathway between inactivity and activity, isolation and socialization, depression and hope, and from being an observer of life to an active participant."

It’s All about the Patient!

Thank You

REFERENCES American Association of Cardiovascular & Pulmonary Rehabilitation, GUIDELINES FOR PULMONARY REHABILITATION PROGRAMS, Third Edition 2004, Human Kinetics: Champaign, ILL. 1-800-747-4457 or www.HumanKinetics.com American Thoracic Society/European Respiratory Society Statement on Pulmonary Rehabilitation. Am J Respir Crit Care Med 2006; 173:1390-1413 www.atsjournals.org Global Initiative for Chronic Obstructive Lung Disease. Global Initiative for Chronic Pulmonary disease workshop report: updated 2006, Available from: www.goldcopd.com The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), 2007 Hospital/Critical Access Hospital National Patient Safety Goals. http://www.jcaho.org