london respiratory team value in pulmonary rehabilitation - minimum standards for london ‘quality...
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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
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‘Breathe Better, Feel Good, Do More’’
Pulmonary Rehabilitation
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Format of the Workshop
• Value in PR• LRT Minimum Standards in PR• Comments / Questions x 15 mins• Psychology involvement • Comments / Questions x 10 mins
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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
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Value of pulmonary rehabilitation• Grade A Evidence• 26 hours contact pp• Effect lasts 12 months• MDT• Supported self-care
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Value of Post-Discharge Pulmonary Rehabilitation
• Saves livesPR reduces mortality over 107 weeks
NNT=6
• Reduces re-admissionsThe only intervention in COPD that reduces the very high 3 month readmission rate…Down from 33% to 7%
NNT= 4Puhan et al. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease.
Cochrane Database of Systematic Reviews 2011, Issue 10.
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Value Framework
Health OutcomesPatient definedbundle of care
CostValue=
Health Outcomes Cost of delivering
Outcomes
Porter ME; Lee TH NEJM 2010;363:2477-2481; 2481-2483
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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
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Pulmonary Rehabilitation availability in London in 2010
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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
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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
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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
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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
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Importance of Service DesignRolling 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
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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
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Variation in Completion of PR – Audit 2010 (aiming for 75% of referrals)
% of Referred Patients completing Pulmonary Rehabilitation
0102030405060708090
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LRT – Minimum Standards for PRService•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
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LRT – Minimum Standards for PRInitial 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
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LRT – Minimum Standards for PRProgramme & 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
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LRT – Minimum Standards for PROxygen in PR
• 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
Exercise Prescription and Progression on 3 key exercises
• 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
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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
LRT – Minimum Standards for PR
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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
LRT – Minimum Standards for PR
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Pulmonary Rehabilitation availability in London in 2012
PR available
Commissioned PR now available
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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
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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
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Any Questions?
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Psychology in Chronic Respiratory Disease
- What does it have to offer ?