JOHN MUIR HEALTH PULMONARY REHABILITATION PROGRAM

1. JOHN MUIR HEALTHPULMONARY REHABILITATIONPROGRAM Lana Hilling, RCP, FAACVPR Coordinator, Lung Health Services John Muir Health 925-674-2351 Lana.hilling@johnmuirhealth.com

2. 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

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

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

12. AACVPR

13. Prevention And Outcomes Essential Components of Pulmonary Rehabilitation

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

16. Conditions Appropriate forPulmonary 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

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 • Patient goals • Team goals • Realistic • Short & long term • Emphasis on ADL’s • Long-term adherence

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

23. Identify Barriers to Learning

24. 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

25. Breathing Retraining

26. Correct Inhaler Technique

27. Infection Control Twinkle Twinkle Little Star

28. Self Assessment Techniques

29. 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

30. 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

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

32. Long Term Adherence • 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.

34. Verona Arena, Italy

35. " 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."

36. Heart and Lung Games

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

38. 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."

39. It’s All about the Patient!

40. Thank You

41. 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