Transcript view slides - PFF Summit

PATIENT AND CAREGIVER
PULMONARY REHABILITATION
WORKSHOP
ANNE HOLLAND, PT, PhD
CHRIS D. SCHUMANN, MS, CES, RCEP
TAKING CARE OF YOURSELF:
SHARED HEALTHCARE DECISION-MAKING
NOVEMBER 13, 2015
PULMONARY REHABILITATION
“Is a comprehensive intervention based on a thorough
patient assessment followed by patient tailored therapies
that include, but are not limited to, exercise training,
education, and behavior change, designed to improve
the physical and psychological condition of people with
chronic respiratory disease and to promote the longterm adherence to health-enhancing behaviors.”
American Thoracic Society/
European Respiratory Society
PULMONARY REHABILITATION
• Each program varies, but here are
some common features:
 Outpatient settings
 Lasts 6 to 12 weeks
 Attend 2-3 times/week
 Includes exercise on a stationary
bike, treadmill, arm cycle and light
weights
• You need a referral from your
physician to start a pulmonary rehab
program
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PULMONARY REHABILITATION TEAM
• Interdisciplinary Team:
– Core staff
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Medical Director
Program Manager
Registered Nurse
Respiratory Therapist
Exercise Physiologist
Clerical (Admissions)
– Resource professionals
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Dietitian
Diabetes Educator
Nurse Practitioner
Pulmonary Fellows
Mental Health Specialist (Clinical Psychologist)
Pharmacist
Social Worker
Volunteers
PULMONARY REHABILITATION
SERVICES ARE DESIGNED FOR
THOSE WHO EXPERIENCE LUNG
PROBLEMS SUCH AS:
• COPD
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Bronchitis
Asthma
Bronchiectasis
Cystic Fibrosis
Interstitial Lung Disease
Pulmonary Fibrosis
Pulmonary Hypertension
Pre and post lung transplantation
PULMONARY REHABILITATION
HELPS PARTICIPANTS:
• Experience less difficulty with breathing
• Increase muscle strength and endurance
• Improve your ability to cope with daily activities
• Understand how to use medications and oxygen
appropriately
• Improve your quality of life
• Reduce hospitalizations
AACVPR.ORG
PULMONARY REHABILITATION
PROGRAMS INCLUDE:
• Monitored and supervised exercises
• Education about your pulmonary condition,
control of symptoms, medications, and oxygen
• Assistance with smoking cessation
• Stress reduction and/or management
techniques sessions
• Nutritional counseling/classes
SERVICES PROVIDED IN PULMONARY
REHABILITATION
Exercise assessment
Assessment of O2 requirements
Exercise training
Education topics related to disease
management
• Nutrition evaluation and counseling
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Pulmonary Rehabilitation Assessment
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PULMONARY REHABILITATION
• Medical history review
– PFT, CXR, Clinic visit, etc.
• Medications
• Oxygen
– O2 flowrate at rest and with activity
• Resting vitals
– O2 saturation, HR, BP, baseline shortness of breath rating,
ECG if necessary
• Baseline questionnaire
– Health-related quality of life, Psychosocial, Mood, Diet, etc.
EXERCISE ASSESSMENT
• Essential to allow an individualized
exercise prescription
• Often includes a 6-minute walk test
• Sometimes a cycle exercise test
• Gives lots of useful information:
– How much exercise you can do
– Heart rate responses to exercise
– Oxygen desaturation during exercise
– Symptoms – often breathlessness, but often leg fatigue
too
– Limitations to exercise – eg lower limb arthritis
ASSESSING OXYGEN NEEDS
• At Rest
– Oxygen need may not be needed in early stages of disease.
• Supply meets demand
• With Exercise
– Desaturation is the hallmark feature of PF
• Hypoxemia results in:
– Increase in pulmonary vascular resistance (VR)
– Increased myocardial work
– Decreased oxygen delivery to muscles
» Symptoms, muscle fiber/cellular changes
– The increased VR can increase pulmonary artery pressure
• Your PR team will assess your current oxygen needs both
at rest and during exercise
Exercise Prescription for Pulmonary Patients
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EXERCISE TRAINING IN PULMONARY
REHABILITATION
• Tailored to your needs
• General goals of exercise:
– Increase strength and endurance
– Increase functional capacity
– Improve quality of life
– Reduce symptoms
• Likely that with expert exercise prescription and
supervision, you can do more than you expect
• Goal: 30 mins of endurance exercise
(we work up to it!)
EXERCISE TRAINING
• Maintain adequate oxygen saturation
during exercise, >88%.
– Understand O2 flowrate requirements with
various levels of exercise intensity
– Understand the portable oxygen system better
(demand vs. continuous)
– Understand how pacing and breathing techniques
might help
ATS/ERS, AJRCCM 10/2013
HOW MUCH EXERCISE?
• FITT Principle – Frequency, Intensity, Time, Type
– Endurance training
• Frequency – 3-5 days per week
• Intensity – >60% of maximal work rate (moderate)
• Time – 20 to 60 minutes
• Type – walking, treadmill, stationary cycle, etc.
ATS/ERS, AJRCCM 10/2013
HOW MUCH EXERCISE?
• FITT
– Frequency, Intensity, Time, Type
– Strength training
• Frequency – 2-3 days per week
• Intensity – 60-70% of one repetition max
8-12 repetitions
1-3 sets
• Time – 20-30 minutes
• Type – 8-10 exercises (Upper and lower body)
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HOW MUCH EXERCISE?
• Flexibility Training
– 2-3 days per week
– Perform upper and lower body flexibility exercises
• Major muscle groups
• Focus placed on good posture and proper breathing
techniques
– NOT a substitute for endurance and strength
training
– (if you have to pick one type of exercise,
don’t pick this one)
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Non-exercise components of
Pulmonary Rehabilitation
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NON-EXERCISE COMPONENTS
• Often find yourself in an education group with people who
have other lung diseases
• Some education and management topics are common across
disease groups:
– how the lungs work, establishing a home exercise program,
healthy eating, using oxygen etc
• Some are different
– treatments and their side effects, participating in clinical
trials, managing cough
• Your team will tailor your program to your needs
NON-EXERCISE COMPONENTS
• Pulmonary rehabilitation is a great opportunity to maximize
your health across a range of important areas
• A range of health care professionals often available to help you
to do this:
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Nurse
Nutritionist
Diabetes Educator
Pharmacist
Social Worker
Is there scientific evidence to support
pulmonary rehabilitation in PF?
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SCIENTIFIC EVIDENCE TO
SUPPORT PR IN PF?
Better with PR
Line of no effect
0.68
6MWD, n=168
Peak exercise
capacity, n=80
0.65
Significant gains in
exercise capacity,
symptoms and
quality of life
0.66
Dyspnoea, n=113
HRQOL, n=106
Physical activity,
n=21
Effects are big
enough for
most people to
notice
0.59
0.60
-0.80 -0.60 -0.40 -0.20 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40
Effect Size and 95% confidence interval
Dowman et al Cochrane 2014
SCIENTIFIC EVIDENCE FOR PR
• Studies have demonstrated
improvements in exercise
capacity, symptoms and
health-related quality of life
in patients with PF following
PR
• Longer term benefits less
clear
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Maintaining the benefits of
pulmonary rehabilitation
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MAINTAINING THE BENEFITS OF PR:
THE BIGGEST CHALLENGE
Holland et al Thorax 2008
MAINTAINING THE BENEFITS OF PR:
THE BIGGEST CHALLENGE
• Developing a home exercise program is critical
• Work out what type of exercise you like
(or don’t dislike!)
• Test out your home program whist you are in the
supervised rehab program, so that there is someone
who can help you troubleshoot
Holland et al Thorax 2008
Coverage of PR
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PRIMARY INSURANCE COVERAGE AND
COPAYS
Coverage is typical, but not guaranteed. Coverage will
depend on your specific plan and diagnosis.
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Medicare - 80% coverage
Secondary Insurance – 20%
Traditional primary insurance - 80% coverage
CMS
CY 2016 Proposed Payment Rates
HCPCS Code
Service
Status
Indicator
APC
Payment Rate
Co-Payment
G0237
Therapeutic procd. strg. endur. Q1
7733
$93.27
$18.66
G0238
Oth. resp. proc., indiv.
Q1
5733
$56.70
$11.34
G0239
Oth. resp. proc., group.
Q1
5732
$31.03
$6.21
Questions?
Thank you.