JOHN MUIR HEALTHJOHN MUIR HEALTH

PULMONARY PULMONARY REHABILITATIONREHABILITATION

PROGRAMPROGRAM

Lana Hilling, RCP, FAACVPRLana Hilling, RCP, FAACVPRCoordinator, Lung Health Services Coordinator, Lung Health Services John Muir Health John Muir Health 925-674-2351 925-674-2351 Lana.hilling@johnmuirhealth.com Lana.hilling@johnmuirhealth.com

How to Refer to PRHow to Refer to PR

Call the PRP at 674-2351 ORCall the PRP at 674-2351 OR Fax Physician Referral 674-2036 Fax Physician Referral 674-2036

Required information/testsRequired information/tests

Recent H&P and office notesRecent H&P and office notes Complete PFT with DLCO (within past year)Complete PFT with DLCO (within past year) EKGEKG Chest X-RayChest X-Ray CBCCBC ABG, if patient already has oneABG, if patient already has one

John Muir Medical Center, Concord Campus PH (925) 674-2351 FAX (925) 674-2036

PULMONARY REHABILITATION PHYSICIAN REFERRAL

PATIENT’S NAME: DOB: PHONE

REFERRING PHYSICAN: PHONE

I. Pulmonary Diagnosis:

II. Physician to complete: The following are requirements for entrance into the Pulmonary Rehabilitation Program. Please provide copies of each item below, along with this form.

The patient is capable of participating in the program Y N

Patient is currently an active smoker Y N

Patient is willing to participate in smoking cessation activities Y N

REQUIRED DATA: (Within 1 Year, Unless Otherwise Specified)

H & P or Pulmonary Consultation within 90 days (hospital or office) Y N

Complete PFT Y N

CXR Y N

EKG Y N

CBC (within 90 days) Y N

OPTIONAL DATA: (But Preferred)

ABG Y N

Exercise stress test Y N

Oxywalk or 6-Minute Timed Distance Walk Test Y N

Your signature below allows the Pulmonary Rehabilitation staff to order any of the above required tests which have not been done, as they are needed for participation in the program.

SIGNATURE_______________________________________ DATE______________________

COPD StatisticsCOPD Statistics COPD is the 4COPD is the 4thth leading cause of death leading cause of death

((only top killer with increasing mortalityonly top killer with increasing mortality)) COPD ranks second as a cause of COPD ranks second as a cause of

disabilitydisability 12 million+ have COPD12 million+ have COPD

On average only 10-15% of these eligible On average only 10-15% of these eligible candidates receive Pulmonary Rehabcandidates receive Pulmonary Rehab

Another 12 million may have it but Another 12 million may have it but don’t know itdon’t know it 1 out of 6 Americans with COPD has never 1 out of 6 Americans with COPD has never

smokedsmoked

COPD Statistics COPD Statistics (Cont’d)(Cont’d)

COPD is responsible for more than 10 COPD is responsible for more than 10 million doctor’s visits per year, 1.5 ED million doctor’s visits per year, 1.5 ED visits and 600,0000 hospitalizationsvisits and 600,0000 hospitalizations

(GOAL OF PR—Decrease hospitalizations, (GOAL OF PR—Decrease hospitalizations, length of stay and ED visits)length of stay and ED visits)

COPD cost US - total $32.1 billionCOPD cost US - total $32.1 billion Next 20 years-total ~ $832.9 Next 20 years-total ~ $832.9

billionbillion

COPDCOPD

Percent Change in Age-AdjustedDeath Rates, U.S., 1965-1998Percent Change in Age-AdjustedDeath Rates, U.S., 1965-1998

00

0.50.5

1.01.0

1.51.5

2.02.0

2.52.5

3.03.0

Proportion of 1965 RateProportion of 1965 Rate

0 .0

0 .5

1 .0

1 .5

2 .0

2 .5

3 .0

1965 - 19981965 - 1998 1965 - 19981965 - 1998 1965 - 19981965 - 1998 1965 - 19981965 - 1998 1965 - 19981965 - 1998

–59%–59% –64%–64% –35%–35% +163%+163% –7%–7%

CoronaryHeart

Disease

CoronaryHeart

Disease

StrokeStroke Other CVDOther CVD COPDCOPD All OtherCauses

All OtherCauses

Pulmonary Rehabilitation Pulmonary Rehabilitation PR recognized as integral component ofPR recognized as integral component of standard quality medical therapystandard quality medical therapy Strategies, therapeutic interventions and Strategies, therapeutic interventions and Disease Management Principles are Disease Management Principles are well establishedwell established Documented benefits are substantialDocumented benefits are substantial Expanding beyond the COPD patient to otherExpanding beyond the COPD patient to other Chronic Respiratory Conditions for patients Chronic Respiratory Conditions for patients

withwith symptoms or reductions in functional statussymptoms or reductions in functional status despite despite optimal medical therapyoptimal medical therapy

ATS/ERS ATS/ERS Pulmonary Rehabilitation Pulmonary Rehabilitation

DefinitionDefinition

““PR is an PR is an evidence-based, evidence-based, multidisciplinary, and comprehensive multidisciplinary, and comprehensive interventionintervention for patients with chronic for patients with chronic respiratory diseases who are respiratory diseases who are symptomatic symptomatic and often have and often have decreased daily life activitiesdecreased daily life activities. .

ATS/ERS ATS/ERS Pulmonary Rehabilitation Pulmonary Rehabilitation

Definition Definition (con’d)(con’d)

Integrated into the individualized Integrated into the individualized treatment of the patient, PR is treatment of the patient, PR is designed todesigned to reduce symptoms, reduce symptoms, optimize functional status,optimize functional status, increase increase participation and reduce health care participation and reduce health care costscosts through through stabilizing or reversing stabilizing or reversing systemic manifestations of the systemic manifestations of the diseasedisease.”.”

ChallengesChallenges

Remaining Skepticism from the Remaining Skepticism from the

medical community medical community Lack of enthusiasm from some physiciansLack of enthusiasm from some physicians Insufficient numbers of referrals andInsufficient numbers of referrals and

delays in referralsdelays in referrals Inadequate program availability in someInadequate program availability in some

regions of the countryregions of the country CMS National Coverage Policy currently CMS National Coverage Policy currently

being written is unacceptablebeing written is unacceptable

Goals of Pulmonary Goals of Pulmonary RehabRehab

Control & alleviate symptomsControl & alleviate symptoms Improve quality of lifeImprove quality of life Increase exercise toleranceIncrease exercise tolerance Promote self-reliance & Promote self-reliance &

independence (ADLs)independence (ADLs) Decrease use of medical Decrease use of medical

resourcesresources

AACVPRAACVPR

Essential Components of Pulmonary Rehabilitation

Promotion of long-term adherence

Education/training

Assessment

Therapeutic Exercise

Psychosocial intervention

PreventionAnd

Outcomes

Interdisciplinary TeamInterdisciplinary Team

Medical Directors Medical Directors Dr. Richard Kops, Concord Campus Dr. Richard Kops, Concord Campus Dr. Karin Cheung, Walnut Creek CampusDr. Karin Cheung, Walnut Creek Campus

Program Coordinator/DirectorProgram Coordinator/Director Rehabilitation SpecialistRehabilitation Specialist PatientPatient Referring physicianReferring physician Respiratory TherapistRespiratory Therapist Physical TherapistPhysical Therapist DietitianDietitian PharmacistPharmacist Social WorkerSocial Worker

DATE: Tuesday 3-13-07 WEEK 1 10-00-11:00 Introduction & Pre-Testing11:00-12:00 Respiratory System: Structure and Function 12:00-1:30 Exercise

DATE: Thursday 3-15-0710:00-11:00 Support Group11:00-12:00 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 12:00-1:30 Exercise

DATE: Thursday 3-22-079:00-10:30 Dietary Evaluations Medication Consults10:30-11:00 Medications 11:00-12:00 Self Assessment 12:00-1:30 Exercise

DATE: Tuesday 3-27-07WEEK 3 10:00-11:00 Exercise Principles 11:00-12:00 Your Food Life 12:00-1:30 Exercise

DATE: Thursday 3-29-0710:00-11:00 Support Group/Stress Management11:00-12:00 ADLs12:00-1:30 Exercise

DATE: Tuesday 4-3-07WEEK 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 4-5-0710:00-11:00 Support Group/ Relaxation Techniques11:00-12:00 Post-Testing 12:00-1:30 Exercise1:30 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., 11:45 – 1:00 Exercise Home Exercise Prescription

Conditions Appropriate forConditions Appropriate forPulmonary RehabilitationPulmonary Rehabilitation

Obstructive DiseasesObstructive Diseases Restrictive DiseasesRestrictive Diseases Chest wall diseases Chest wall diseases Neuromuscular diseases Neuromuscular diseases Other conditionsOther conditions

Lung cancerLung cancer Primary pulmonary hypertensionPrimary pulmonary hypertension Pre and post thoracic and abdominal surgeryPre and post thoracic and abdominal surgery Pre and post lung transplantationPre and post lung transplantation Pre and post lung volume reduction surgeryPre and post lung volume reduction surgery Ventilator dependency Ventilator dependency Obesity-related respiratory diseaseObesity-related respiratory disease

Patient Selection CriteriaPatient Selection Criteria

Appropriate ConditionsAppropriate Conditions Degree of impairment in PFT commonly usedDegree of impairment in PFT commonly used

PFT – FVC, FEV1, and /or DLCO < 65%PFT – FVC, FEV1, and /or DLCO < 65%

((helpful helpful butbut symptoms correlate better with symptoms correlate better with

functional ability)functional ability) Reduction in physical activity, occupational performance, ADL’s occupational performance, ADL’s andand increased consumption of medical increased consumption of medical

resourcesresources

Patient Selection CriteriaPatient Selection Criteria

Possible contraindications for PRPossible contraindications for PR Unstable Cardiac DiseaseUnstable Cardiac Disease Severe Pulmonary HypertensionSevere Pulmonary Hypertension Other concurrent diseases or conditionsOther concurrent diseases or conditions Use of tobaccoUse of tobacco MotivationMotivation Financial concernsFinancial concerns Transportation problemsTransportation problems

Disease States that Disease States that may require modificationsmay require modifications Advanced liver diseaseAdvanced liver disease StrokeStroke Cognitive deficit and psychiatric diseaseCognitive deficit and psychiatric disease

Patient AssessmentPatient Assessment Patient InterviewPatient Interview Medical HistoryMedical History Physical ExamPhysical Exam Diagnostic TestsDiagnostic Tests Symptoms AssessmentSymptoms Assessment Musculoskeletal & Exercise AssessmentMusculoskeletal & Exercise Assessment Nutritional AssessmentNutritional Assessment Educational AssessmentEducational Assessment Psychosocial AssessmentPsychosocial Assessment Goal DevelopmentGoal Development

GOALSGOALS

GoalsGoals Patient goalsPatient goals Team goals Team goals RealisticRealistic Short & long termShort & long term

Emphasis on ADL’sEmphasis on ADL’s

Long-term adherenceLong-term adherence

Objective of Patient Objective of Patient Education/ TrainingEducation/ Training

Encourage behavioral change Encourage behavioral change Improved healthImproved health Patients active in their health carePatients active in their health care Achieve optimal levels of understanding Achieve optimal levels of understanding

and self-managementand self-management Commitment to long-term Commitment to long-term

adherenceadherence

Teaching Styles Teaching Styles (Cont’d)(Cont’d)

Treat Patients Like AdultsTreat Patients Like Adults Responsible for what they learnResponsible for what they learn

Clearly State Clearly State WWhy hy and and HHowow information is information is importantimportant Link it to their daily activitiesLink it to their daily activities

Build a trusting relationship with the Build a trusting relationship with the patientspatients

There are no stupid questions or There are no stupid questions or answersanswers

Identify Barriers to LearningIdentify Barriers to Learning

Education and Skills TrainingEducation and Skills Training

Normal A & P and the Disease ProcessNormal A & P and the Disease Process Oxygen RationaleOxygen Rationale Activities of Daily LivingActivities of Daily Living Benefits of Exercise Benefits of Exercise Nutrition GuidelinesNutrition Guidelines Smoking Cessation/hazards of secondhand Smoking Cessation/hazards of secondhand

smokesmoke

Breathing RetrainingBreathing Retraining

Correct Inhaler Correct Inhaler TechniqueTechnique

Infection ControlInfection Control

Little

Twinkle Twinkle

Star

Self Assessment Self Assessment TechniquesTechniques

Exercise TrainingExercise Training DurationDuration FrequencyFrequency Mode Mode IntensityIntensity Exercise PrescriptionExercise Prescription

Endurance trainingEndurance training Strength trainingStrength training Specific techniquesSpecific techniques

Upper and lower extremity exercisesUpper and lower extremity exercises

Posture and Body MechanicsPosture and Body Mechanics Respiratory Muscle TrainingRespiratory Muscle Training StretchingStretching

Home exercise Prescription/Maintenance Home exercise Prescription/Maintenance ExerciseExercise

Psychosocial ComponentPsychosocial Component

Critical to the success of PRCritical to the success of PR Depressive symptoms may contribute Depressive symptoms may contribute

more to functional disability, poor health more to functional disability, poor health perception and poor well-being than the perception and poor well-being than the chronic medical condition itselfchronic medical condition itself

Support GroupSupport Group Learn coping skillsLearn coping skills

Stress management/relaxation techniquesStress management/relaxation techniques Anger managementAnger management

Psychosocial ComponentPsychosocial Component

Ethical Issues AddressedEthical Issues Addressed Advanced DirectivesAdvanced Directives Limitation of medical intervention by Limitation of medical intervention by

paramedicsparamedics Address Issues of SexualityAddress Issues of Sexuality Refer for counseling and or medicationsRefer for counseling and or medications

Long Term AdherenceLong Term Adherence PR is a Commitment to a lifestyle changePR is a Commitment to a lifestyle change Short term interventions do not result in long term Short term interventions do not result in long term

gainsgains Patients must continue to participate in their Patients must continue to participate in their

exercise regimes and other adopted lifestyle exercise regimes and other adopted lifestyle changeschanges

Emphasis on relapse prevention strategiesEmphasis on relapse prevention strategies Develop a plan to promote and reinforce strategies Develop a plan to promote and reinforce strategies

learnedlearnedPersonal lifestyle changes are made by a person, Personal lifestyle changes are made by a person, not a plannot a plan..

Verona Arena, ItalyVerona Arena, Italy

Heart and Lung GamesHeart and Lung Games

Second International Second International Heart and Lung Games Heart and Lung Games

Chicago, IL 2006Chicago, IL 2006

Patient DefinitionPatient Definition

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

It’s All about the Patient!It’s All about the Patient!

Thank YouThank You

REFERENCESREFERENCES

American Association of Cardiovascular & Pulmonary American Association of Cardiovascular & Pulmonary Rehabilitation, GUIDELINES FOR PULMONARY Rehabilitation, GUIDELINES FOR PULMONARY REHABILITATION PROGRAMS, Third Edition 2004, Human REHABILITATION PROGRAMS, Third Edition 2004, Human Kinetics: Champaign, ILL. 1-800-747-4457 or Kinetics: Champaign, ILL. 1-800-747-4457 or www.HumanKinetics.com

American Thoracic Society/European Respiratory Society American Thoracic Society/European Respiratory Society Statement on Pulmonary Rehabilitation. Am J Respir Crit Statement on Pulmonary Rehabilitation. Am J Respir Crit Care Med 2006; 173:1390-1413 Care Med 2006; 173:1390-1413 www.atsjournals.org

Global Initiative for Chronic Obstructive Lung Disease. Global Initiative for Chronic Obstructive Lung Disease. Global Initiative for Chronic Pulmonary disease workshop Global Initiative for Chronic Pulmonary disease workshop report: updated 2006, Available from: report: updated 2006, Available from: www.goldcopd.com

• The Joint Commission on Accreditation of Healthcare The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), 2007 Hospital/Critical Access Organizations (JCAHO), 2007 Hospital/Critical Access Hospital National Patient Safety Goals. Hospital National Patient Safety Goals. http://www.jcaho.org