1. JOHN MUIR HEALTH PULMONARY REHABILITATION PROGRAM
Lana Hilling, RCP, FAACVPR
Coordinator, Lung Health Services
John Muir Health

2. How to Refer to PR Call the PRP at 674-2351 OR
Fax Physician Referral
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

4. 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

5. 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

6. 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

7. 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

8. 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.

9. 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.”

10. 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

11. 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.

12. AACVPR

13. Essential Components of Pulmonary Rehabilitation
Prevention
And
Outcomes

14. 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

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

16. 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.

17. 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

18. 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

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

20. 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.

21. 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

22. 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

23. 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

24. Identify Barriers to Learning

25. 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

26. Breathing Retraining

27. Correct Inhaler Technique

28. Infection Control
Twinkle
Twinkle
Little
Star

29. Self Assessment Techniques

30. 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

31. 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

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

33. 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.

35. Verona Arena, Italy

36. " 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."

37. Heart and Lung Games

38. Second International Heart and Lung Games Chicago, IL 2006

39. 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."

40. It’s All about the Patient!

41. Thank You

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