London Respiratory Team Value in Pulmonary Rehabilitation - Minimum Standards for London

1. London Respiratory Team Value in Pulmonary Rehabilitation - Minimum Standards for London ‘Quality with Equality’ Maria Buxton – Consultant Respiratory Physiotherapist - Pulmonary Rehab Lead for LRT Simon Dupont – Head of Clinical Health Psychology – Hillingdon Hospital

2. Pulmonary Rehabilitation ‘Breathe Better, Feel Good, Do More’’

3. Format of the Workshop • Value in PR • LRT Minimum Standards in PR • Comments / Questions x 15 mins • Psychology involvement • Comments / Questions x 10 mins

4. LRT Key Messages – 2010Pulmonary Rehabilitation- What we set out to do • Commission an integrated COPD pathway that includes PR, with shared responsibility for outcomes • Increase the demand for, and supply of PR, to match the number of patients who would benefit • Agree pan-London definitions & standards to enable comparison • Increase demand using positive message "Breathe better,feel good, do more” • Refer people on optimal not necessarily maximal therapy: consider offering PR before triple therapy

5. Value of pulmonary rehabilitation • Grade A Evidence • 26 hours contact pp • Effect lasts 12 months • MDT • Supported self-care

6. Value of Post-Discharge Pulmonary Rehabilitation • Saves lives • PR reduces mortality over 107 weeks • NNT=6 • Reduces re-admissions • The only intervention in COPD that reduces the very high 3 month readmission rate… • Down from 33% to 7%NNT= 4 Puhan et al. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2011, Issue 10.

7. Value Framework Health Outcomes Patient defined bundle of care Value = Health Outcomes Cost of delivering Outcomes Cost Porter ME; Lee TH NEJM 2010;363:2477-2481; 2481-2483

8. To Get…..best Value How much for what impact on how many????? • Health Outcomes / Cost of Service • Health outcomes = quality of life, functional capacity, exacerbations, admission, re-admissions, health status, self esteem, coping mechanisms • Cost of Service - efficiency optimal but not to sacrifice quality

9. Pulmonary Rehabilitation availability in London in 2010

10. What do we want from PR? • As many appropriate patients as possible have access to a local PR programme • Patients are identified and encouraged to attend by all HCP at every opportunity • PR is easy to get to, or back into - potential barriers for non attendance are removed e.g. improved locations, transport provision, language support, social/financial signposting, fluid system of re-entry if exacerbations occur • From start to finish – PR is a quick process - no longer than 16 weeks – (referral to starting programme = 10 weeks, and programme is 6 weeks long) unless exacerbating, in which case a longer end point is acceptable • As many patients as possible complete PR – recommend that 75% of all eligible referrals complete 75% of the classes – tough but achievable if address all points above, and service financially supported to deliver • All patients +/- family & carers enjoy PR and gain from it – enjoy social interaction & peer support, demonstrable benefits in quality of life, walking distance, health status, and reduced potential to be admitted to hospital • All patients are encouraged and motivated to continue with exercise after PR and there is local support available to achieve this

11. Reality Check • If we want all of that for our patients – we need to pay for it. • Paying lip service and going ‘cheap’ to tick the box will not deliver the health outcomes promised / potential • To deliver it in as efficient way as possible, to minimise waste • PR in isolation will not deliver potential health outcomes unless part of an integrated service

12. Pulmonary Rehabilitation Terminology • Provider - institution that delivers PR as a service • Service - All the PR programmes delivered by the provider plus the admin and surrounding work required to deliver the PR programmes • Programme – set yearly availability of PR - set occasions during the week that PR run throughout year - either cohort or rolling, e.g. Mons & Thurs would be 1 programme; if add in Tues & Fri would be 2 programmes • Course - 1 completed PR course per patient (e.g 6-8 weeks long) • Class - individual hourly sessions within the course

13. Importance of Service Design - ValueType of Programme – explanation & impact Cohort – 1 course intake at a time e.g. 12 patients – whole group starts on wk 1 and completes on wk 6 Rolling – patients enter course each week, stay for 6 weeks and leave. There is a constant flux of patients within group – starters and leavers each week. Semi-rolling – 3 weekly crossover – each group stays for 6 weeks, but enter / leave at 3 weekly intervals • Efficiency good in Rolling and Semi-rolling as can address DNA’s better and utilise spare capacity- maximise group numbers and reduce wait times • Social peer support and interaction good in Cohort and Semi-rolling – could minimise drop out and increase motivation to complete

14. Importance of Service Design Rolling vs Cohort vs Semi-Rolling………..issues to consider for value • Cohort – waste potential - average - 30% drop out during programme = 4 out of 12 places not utilised • Semi-rolling – addresses efficiency whilst maintaining social support of a cohort group • Waiting times will impact on drop out – reduce efficiency and completion rates - key areas to address - referral to assessment and assessment to start of course • Can have multiple programmes with both designs – address population/cultural needs and potential to improve completion • Staffing implications – rolling more demanding of staffing than semi and cohort • If part of integrated respiratory services – drop outs due to exacerbations can be followed up immediately and re-inserted into PR quickly • Motivation related drop outs can be followed up if service has capacity to contact patients who DNA and re-engage / motivate them to come back, working closely with GP and other involved HCPs to achieve this

15. Importance of Service Design - 2 • Psychology input – potential to address behaviour change, motivation and completion • Exercise standards around prescription and progression should follow recognised international guidance to achieve full potential of published health benefits • Quality - review of outcomes and bench mark against peers • Set realistic expectations of capacity and throughput and ‘phasing’ in of newer services in historically unresourced areas – don’t set out to fail a new service by unrealistic targets • Close collaboration with commissioners to advise / discuss above points – to create a definitive realistic ,achievable, high value service for the local population • Set KPI’s to address efficiency, outcomes, and quality

16. Variation in Completion of PR – Audit 2010 (aiming for 75% of referrals)

17. LRT – Minimum Standards for PR Service • Referral to start of Programme 10 weeks • At least 2 venues on offer in accessible geographically separated locations • Attendance documentation • Transport available • Completion definition = 75% of classes attended • MCID reached in 75% of completers for ISWT or CAT • Regular data collection, with annual report for service • Appropriate level of admin support by appropriate band/profession of staff • Post PR follow on exercise promoted and available locally • Core Clinical staff experienced in chronic respiratory disease • Respiratory Physician / GPwSI involved in Clinical Governance, not necessary in core provider team

18. LRT – Minimum Standards for PR Initial Assessment – Streamlined to encourage efficiency • Chronic Obstructive Pulmonary Disease (COPD) Assessment Test TM (CAT) • Hospital Anxiety and Depression Scale (HADS)OR equivalent (PHQ or GAD - (mental health assessments used in primary care) • Incremental Shuttle Walking Test (ISWT) x 2 (practice walk must be included) • Holistic assessment (not including routine spirometry) • Current drug regimen review in light of disease severity and exacerbation frequency, and feedback to referrer/GP with recommendations of up/down titrate drugs if not on optimal (not necessarily maximal) inhaled therapy • Goal setting and motivational interviewing

19. LRT – Minimum Standards for PR Programme & Course • Rolling / Semi-Rolling Programme - 2 x week • Further home based exercise on 2 occasions during week • 6 weeks long • 2 staff in attendance ( 1 is a physio) for exercise as a minimum, and 1:8 staff : patient ratio • Evidence of endurance and strength assessment with appropriate exercise prescription and progression throughout. On at least 3 key Quads focused exercises in the field – sit to stand, step up and walking - details later • Not all oxygen desaturators have to have supplemental oxygen during exercise • Evidence of personalised goal setting and review • Education – comprehensive programme, delivered by a MDT with experience in respiratory disease, • Psychology input – utilise for value – in assessment or 1:1 with patients, rather than lecture groups

20. LRT – Minimum Standards for PR Oxygen in PR Exercise Prescription and Progression on 3 key exercises • Supplemental oxygen does not have to be worn by all patients who significantly desaturate, and potential risks / reduced benefit with exercise should be discussed with each patient • If patients agree - referral onto AO clinics • Patients who refuse / are awaiting AO can still exercise in PR without AO • No routine spot checking of oxygen saturations during PR necessary • Clinical judgement is required for each individual patient • Quads focus – strength and endurance • 3 field exercises – sit to stand, step ups, and walking speed • Sit to stand and step ups – Max test on Wk1, 3 and 5 • Prescribe at 75% of max x 2 reps • Walking – ESWT (85% of VO2 - ISWT) speed over 10m course, using CD’s and personal headphones x 10 mins • Time spent on aerobic exercising – at least 20 mins out of 60

21. LRT – Minimum Standards for PR Education Content of Course • Lung anatomy & physiology • Disease pathology education • Drug regimens (including oxygen use) and inhaler techniques • Self-management in stable and exacerbation states • Breathlessness – causes of and interventions • Exercise – why, what and when in chronic respiratory conditions • Diet • Mental health and CBT approach to behaviour change • Stop smoking • Sputum clearance • Psycho-social issues – family impact, impact on mental health, benefits, services, self help groups e.g. Breathe Easy

22. LRT – Minimum Standards for PR Final Assessment • - Goal review • - ISWT x 1 • - CAT • -HADS or other test if relevant • - Patient experience • - Self management plan review to include ongoing exercise plan • - Referral onward to other services/exercise class • - Report written to GP + referrer if not GP

23. Pulmonary Rehabilitation availability in London in 2012 PR available Commissioned PR now available

24. Pulmonary Rehabilitation Re-Audit London 2013 • Repeat audit sent – awaiting replies • Harrow & Enfield still do not have PR, BUT, Enfield has started the commissioning process. • Harrow – still nothing • New areas starting PR – Kingston, Havering, Hounslow, - developing services and providing PR in multiple programmes • Ealing – bigger service than before – 3 programmes • Final Re-audit will show development of new commissioning strategies, and whether existing services have been effected by CCG’s / DOH Commissioning pack publication

25. Additional Resources available • DOH – Commissioning toolkits – Specification, Costing https://www.gov.uk/government/publications/commissioning-toolkit-for-respiratory-services • http://www.networks.nhs.uk/nhs-networks/south-east-coast-respiratory-programme/breathing-matters-the-south-east-coast-newsletter - articles by Julia Bott on PR Ax, Exercise Testing and Prescription

26. Any Questions?

27. Psychology in Chronic Respiratory Disease - What does it have to offer ?