Transcript CCHP 10-09 (2nd)

JOHN MUIR HEALTH
PULMONARY REHABILITATION
PROGRAM
Lana Hilling, RCP, FAACVPR
Coordinator, Lung Health Services
John Muir Health
925-674-2351
[email protected]
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
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
Patient is currently an active smoker
Patient is willing to participate in smoking cessation activities
Y
Y
Y
N
N
N
REQUIRED DATA: (Within 1 Year, Unless Otherwise Specified)
H & P or Pulmonary Consultation within 90 days (hospital or office)
Complete PFT
CXR
EKG
CBC (within 90 days)
Y
Y
Y
Y
Y
N
N
N
N
N
OPTIONAL DATA: (But Preferred)
ABG
Exercise stress test
Oxywalk or 6-Minute Timed Distance Walk Test
Y
Y
Y
N
N
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 Statistics
 COPD is the 4th leading cause of death
(only top killer with increasing mortality)
 COPD ranks second as a cause of disability
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12 million+ have COPD
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On average only 10-15% of these eligible
candidates receive Pulmonary Rehab
Another 12 million may have it but don’t
know it
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1 out of 6 Americans with COPD has never
smoked
COPD Statistics (Cont’d)
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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
Percent Change in Age-Adjusted
Death Rates, U.S., 1965-1998
Proportion of 1965 Rate
3 . 03.0
2 . 52.5
Coronary
Heart
Disease
Stroke
Other CVD
COPD
All Other
Causes
–59%
–64%
–35%
+163%
–7%
1965 - 1998
1965 - 1998
1965 - 1998
1965 - 1998
1965 - 1998
2 . 02.0
1 . 51.5
1 . 01.0
0 . 50.5
0 .0 0
Pulmonary Rehabilitation
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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
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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
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AACVPR
Essential Components of
Pulmonary Rehabilitation
Promotion of longterm adherence
Psychosocial
intervention
Education/training
Prevention
And
Outcomes
Therapeutic Exercise
Assessment
Interdisciplinary Team
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Medical Directors
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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
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
12:00-1:30
Exercise
DATE: Thursday 3-22-07
9:00-10:30
Dietary Evaluations
Medication Consults
10:30-11:00 Medications
11:00-12:00 Self Assessment
12:00-1:30
Exercise
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
12:00-1:30
Exercise
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
12:00-1:30
Exercise
1:30
Advance Directives
DATES:
4-9, 4-11, 4-13
WEEK 5 MON., WED., FRI.,
11:45 – 1:00 Exercise
DATES:
WEEK 6
4-16, 4-18, 4-20
MON., WED., FRI.,
11:45 – 1:00 Exercise
Home Exercise Prescription
Conditions Appropriate for
Pulmonary Rehabilitation
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Obstructive Diseases
Restrictive Diseases
Chest wall diseases
Neuromuscular diseases
 Other conditions
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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
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
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Possible contraindications for PR
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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
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Advanced liver disease
Stroke
Cognitive deficit and psychiatric disease
Patient Assessment
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Patient Interview
Medical History
Physical Exam
Diagnostic Tests
Symptoms Assessment
Musculoskeletal & Exercise Assessment
Nutritional Assessment
Educational Assessment
Psychosocial Assessment
Goal Development
GOALS
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Goals
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Patient goals
Team goals
Realistic
Short & long term
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Emphasis on ADL’s
Long-term adherence
Objective of Patient
Education/ Training
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Encourage behavioral change
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Improved health
Patients active in their health care
Achieve optimal levels of understanding and
self-management
Commitment to long-term adherence
Teaching Styles (Cont’d)
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Treat Patients Like Adults
 Responsible for what they learn
Clearly State Why and How information is
important
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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
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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
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
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Critical to the success of PR
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Depressive symptoms may contribute more to
functional disability, poor health perception
and poor well-being than the chronic medical
condition itself
Support Group
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Learn coping skills
Stress management/relaxation techniques
 Anger management
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Psychosocial Component
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Ethical Issues Addressed
Advanced Directives
 Limitation of medical intervention by
paramedics
Address Issues of Sexuality
Refer for counseling and or medications
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Long Term Adherence
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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
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
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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