479 COPD9USA Summary: Pulmonary Rehabilitation

Chronic Obstructive Pulmonary Diseases:

Journal of the COPD Foundation

COPD9USA Session Summary

Pulmonary Rehabilitation: Improvement with Movement

Anita Rajagopal, MD1 and Richard Casaburi, MD2

This article serves as a CME-available enduring material summary of the following COPD9USA presentations:
Lessons Learned from Pulmonary Education Program and On Track with COPD Ongoing Health Management. Presenter:
Scott Cerreta, BS, RRT
Cultivating Memorial Funds for Pulmonary Rehabilitation Presenter: Valerie McLeod, RRT
Strategies for Success: Maintenance Program Best Practices Presenter: David Vines, MHS, RRT
Strategies for Success-Maximizing Participation and Completion Rates, Presenter: Trina M. Limberg, BS, RRT

Abbreviations: pulmonary education program, PEP; pulmonary rehabilitation, PR; chronic obstructive pulmonary disease, COPD; Chronic
Care Model, CCM
Citation: Rajagopal A, Casaburi R. Pulmonary rehabilitation: Improvement with movement. Chronic Obstr Pulm Dis (Miami). 2016;
3(1):479-484. doi: http://dx.doi.org/10.15326/jcopdf.2015.3.1.0169

1 Division of Pulmonary, Critical Care, and Sleep Medicine,

University of Kentucky, Lexington, Kentucky
Lessons Learned from Pulmonary
Education Program and On Track
2 Los Angeles Biomedical Research Institute at Harbor-University
of California, Los Angeles Medical Center, Torrance
with COPD Ongoing Health
The goal of the COPD Foundations PEP is to offer an
Address correspondence to:
exceptional experience to pulmonary rehabilitation
Anita Rajagopal, MD
University of Kentucky
(PR) patients with COPD by providing disease-
Division of Pulmonary, Critical Care and Sleep Medicine specific educational materials, improved quality of life,
740 S. Limestone, Ste. L-54 and lifelong engagement in the COPD Community
Lexington, KY 40536 through the PEP On Track with COPD ongoing health
Email: [email protected]
management program.
Keywords: The PEP was launched by the COPD Foundation at
the end of 2012 and has been very successful. It is a
pulmonary rehabilitation; COPD education;
service provided after an individual graduates from a
PR program. The PEP program is currently in 262 PR
Introduction centers (232 active) in 44 states with more than 5000
This material identifies strategies for success in individuals enrolled in the program in 2015.
organizing pulmonary rehabilitation programs and Pulmonary rehabilitation is built around a relationship
discusses limitations to access to and participation in of education, exercise, coping skills, and social bonding.
pulmonary rehabilitation. The presentations center A patient will typically have 12-21 sessions. After
around the Pulmonary Education Program (PEP), graduation, they receive a graduation kit and continue
avenues to establish and promote memorial finds to receive long term benefits. Many patients report less
for pulmonary rehabilitation programs, establishing dyspnea, better adherence, better self-care, and better
effective maintenance programs, using the Chronic quality of life. However, at the end of the program there
Care Model, and individualizing the intervention. can also be a decrease in exercise, increased isolation,

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journal.copdfoundation.org JCOPDF 2016 Volume 3 Number 1 2016

480 COPD9USA Summary: Pulmonary Rehabilitation

and slow loss of benefits gained. This is where the On individuals and Foundation staff.1
Track Programa part of PEP intervenes to fill the gap. As part of the On Track coaching calls, 5 core
The PEP On Track with COPD Ongoing Support questions are asked. See Figure 1. The aim of the calls
Program makes use of a peer-to-peer coaching and questions is to provide ongoing intervention and
curriculum conducted via the COPD Info-line. the opportunity to discuss topics to help prevent a drop
Reaching out to patients through 24 monthly phone in adherence to PR program life-style goals.
calls allows for assessment of the patients progress and In the future, more PR centers will be needed along
encouragement without the need for in-person visits. with more trained associates, improved On Track
These calls can help encourage exercise, reduce the enrollment, collection of better outcomes, and increased
feeling of patient isolation, and maintain the bond that funding.
was formed between patients and the program before The COPD Foundations cost is about $440,000/year
graduation. Through these monthly coaching calls to with the 2 biggest expense components being cost of
patients, goals of improved quality of life and ongoing the educational materials and the cost of the Information
health management can be better obtained. In addition, Line. Improvements to the program are continually
patients are encouraged to become engaged with the made to ensure long term success. The better educated
COPD Foundation through the COPD360social, an patients are, the better they can manage their disease,
interactive, collaborative community where one can which improves outcomes.
join the COPD Foundation, learn about events in ones
area, participate in research, and chat with other COPD

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journal.copdfoundation.org JCOPDF 2016 Volume 3 Number 1 2016

481 COPD9USA Summary: Pulmonary Rehabilitation

and/or do not have specific designations in mind for

Cultivating Memorial Funds for their gift. In these cases, establish a plaque with name
Pulmonary Rehabilitation plates in a prominent place in the gym or provide a
Celebrating patients and their accomplishments, big or variety of inspirational plaques placed throughout the
small, can help to build a strong personal bond which gym to motivate others while honoring contributions to
can be the first step toward establishing a successful the program. This can spark conversations about the
donor/memorial fund for any PR program. program and future contributions.
Even modest PR programs can inspire patients to Memorial gifts, big or small, are an honor to receive
attend regularly by helping the patients understand and can have a significant impact on a PR program.
the program is genuinely interested in their success When a supportive environment is provided for patients
and helping them learn skills that will help them lessen and their families, given the opportunity, they will, in
the burden of their disease and adopt a lifestyle of sit return, support the PR program.
less, move more. Hiring the right staff is crucial to PR Key components for creating a successful PR
success because as staff encourage patients to learn new environment include:
skills, patients realize they can depend on the staff for Recruiting a staff with a passion for the work;
support and reassurance. An important bond is formed. Having medical director and administration
This bond can be reinforced by long-term participation support;
in maintenance exercise programs and making an effort Having adequate space and staffing;
to stay in contact with patients who require a break from Providing value added services (pulmonary
PR due to extenuating life circumstances or hospital function testing, smoking cessation, and community
stays. There should be an emphasis on long-term lung screenings)
relationships and forming an extended family. The Having patient ambassadors
patient-staff relationship is generally what motivates Providing a year-end newsletter
patients to recognize a program via donations. Having a well-organized system in place can lead to
In addition, other important steps to establishing a success both for the PR program and its donor/memorial
donor program include: fund program.
Involving the organizations marketing department;
it is important to keep the program in the forefront Strategies for Success: Maintenance
and visible. Program Best Practices
Networking with the PR organizations foundation
or development department to become aware of Finding adequate PR in rural areas is a challenge. Even
any minimum requirements that may exist for when the program is complete, finding maintenance,
establishing a designated fund. (Without this motivation, and continued support can be an issue for
understanding, memorial gifts will most likely be many individuals.
deposited into a General Fund and may not be A prospective cohort study suggested that physical
available for specific purchases for the PR program.) activity is the strongest predictor of all-cause mortality
Honoring donations with a personal handwritten in patients with COPD.2 The study showed that active
thank you letter to the patient or their family. participants have a higher probability of survival in
Empowering the family or individual to provide comparison to those who are sedentary or very inactive.2
input about how the money will be used. Patients Most patients are not aware that exercise is a strong
often communicate their wishes to family members predictor of mortality. Patients need to understand the
about how to best honor their memory and it is impact that their exercise can have on their survival.
important to listen to these wishes. One study showed that at 6 months there is a benefit
Gifts for the purchase of new equipment can be in maintenance programs.3 However, systematic review
given recognition via a small plaque on the machine of supervised exercise programs after pulmonary
itself, serving to not only honor the donation, but also rehabilitation in individuals with COPD showed that
to spark conversation among patients about memorial benefits seem to be lost after 12 months.3 Health-
contributions. related quality of life gains do not persist at 6 months
Sometimes families like to make smaller donations or 12 months post rehabilitation. There are limitations

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journal.copdfoundation.org JCOPDF 2016 Volume 3 Number 1 2016

482 COPD9USA Summary: Pulmonary Rehabilitation

to these studies including variability between programs management includes education, behavioral support,
and a high drop-out rate. and motivation. A delivery system is designed to
A community-based post-rehabilitation maintenance provide advanced access to medical care (24 h/d, 7 d/
program in COPD was achieved through a partnership wk) and teams to coordinate preventative measures for
with the City of Toronto, Parks, Forestry and Recreation chronic care.8
Division.4 Trained fitness instructors supervised COPD Decision support can be provided through use
patients who attended twice a week. Case managers of evidence-based guidelines, integrated specialty
attended the first exercise session to supervise and assist expertise, identifying barriers to care, and performance
with a modified plan if the participant was absent for 2 reviews. Clinical information systems can be used to
weeks. This led to reported improvements in exercise facilitate clinical registries (population information
capacity and Chronic Respiratory Questionnaire scores databases), clinical reminders, and provider feedback.8
at 6 months and at 1 year. Trust was built between the Telemedicine has made strides in many facets of
patients and the program. Many patients would even medicine. There have been some positive results
contact the program as a first option with health-related using telehealth to deliver PR to patients with COPD
concerns. compared to standard PR. In addition, telehealth may
Barriers to success in exercise programs for COPD play a key role in maintenance programs.
patients include: Sustained results have been difficult to maintain in
Changing health status, personal issues, lack of maintenance programs. Barriers need to be identified
support, external factors, ongoing smoking, barriers and enablers should be encouraged. Best practices
to sustained physical activities5 should include the integration of self-management,
Exacerbations, fatigue, transportation, weather6 health care teams, decision support, and clinical
Lower forced expiratory volume in 1 second scores, information systems. Telemedicine may play a key role
signs of depression, and shorter initial PR7 in maintenance programs.
In contrast, enablers of exercise program success
include: Strategies for Success-Maximizing
Social support, professional support, personal Participation and Completion Rates
benefit, control of condition, specific goals5
Improved function, and quality of life6 PR has long been established as a standard of care
The Chronic Care Model (CCM)8 reminds us we are not improving dyspnea, exercise tolerance and quality of
in this alone. Sometimes PR is separate from primary life in patients with COPD.9-11 Starting and attending
care; these need to be integrated. Immunization status, frequent and lengthy therapy sessions may be more
emergency department visits, and rehab progress need challenging for some patients. A brief review of the
to be communicated to and from the primary care team. literature is useful in understanding why some patients
Collaboration from the community and the health may decline services or why some fail to complete the
system lead to improved outcomes through productive prescribed treatment. Anecdotally, having PR clinicians
interactions. A good maintenance program includes to conduct initial calls to referred patients may help to
self-management support, delivery system design, improve understanding of perceived benefits. Offering
decision support, and a clinical information system. flexible scheduling (when possible) and promoting
These factors coming together lead to an informed and group interaction may help patients to engage and feel
activated patient with a proactive practice team. supported. Clinicians can expect to use the information
In a systematic review of the CCM in COPD to assess factors that may hamper participation in PR.
prevention and management, pooled data demonstrated Several causes have been reported for PR dropout,
that patients with COPD who received interventions some of which are beyond the patients control, such as
with 2 or more CCM components had lower rates acute exacerbations or hospitalizations.12 The impact
of hospitalizations and emergency department/ of out of pocket expenses with applied co-pays remains
unscheduled visits and a shorter length of stay compared relatively unknown in the United States. Several large-
with control groups.8 scale studies have been done in Canada with its different
Components of the CCM can be categorized into payor system. Selzer et al found that 3 factors played a
either self-management or a delivery system. Self- major role in PR drop out: younger patients (average

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journal.copdfoundation.org JCOPDF 2016 Volume 3 Number 1 2016

483 COPD9USA Summary: Pulmonary Rehabilitation

age 63), current smokers, and patients with a lower Once rehabilitation begins, tips for success include:
health status were at risk for dropping out.13 They also Offer group peer-to-peer contact. Involve family
found that pulmonary function data did not predict drop and friends; they need to feel comfortable too.
outs. Perceived impairment was a stronger indicator for Be aware of the environment of the program. Set
predicting drop outs.13 attainable goals at each session.
In another study looking at dropouts and attendance,14 Recognize and offer encouragement when goals are
20% of patients missed appointments due to factors achieved. Be responsive.
beyond their control (exacerbations/hospitalizations). Individualize the program to engage the patient at
Still smoking, living alone, and social factors played a the level that they need. It is important to get it right
role. Lower fat free mass index was very predominant, for the individual patient.
as was lower confidence in the treatment. The focus of Remember that rehab should be fun! This should be
the study was that the emphasis should be placed on an experience that patients dont want to miss and if
nutritional status and on creating a positive expectation they do miss they want to find a way to make up the
of treatment from the very beginning. session.
Keating et al conducted structured interviews of Insurance/Medicare coverage for PR can play an
patients who declined or withdrew from PR and found important role in treatment and out-of-pocket costs can
that a poor perception of benefit and transportation often serve as an inhibitor to participation. Medicare C
barriers were significant.15 A total of 30% of patients can have high co-pays of $40-60 (more than what PR
declined to attend even the first visit. Half of the programs get paid from Medicare). Other inhibitors
patients reported not receiving PR information at the include the limited ability to attend sessions, work
time of referral. In a systematic review also done by schedules (limited availability), transportation issues,
Keating et al, several major areas were identified with poor health literacy, and the inherent barriers of sicker/
regards to starting PR: disruption of routine, transport/ older populations.
travel, influence of physician, lack of perceived benefit Perceived benefits are important, help patients
and inconvenient timing. Illness, comorbidities, and to see the value. A positive referring physician is
depression were major barriers to completing PR.16 influential. Reach out to referrals and communicate
This suggests that the area of focus should be on with them. Flexibility for younger patients and the
building confidence, improving immediate perceived working population is important, as they may have
benefit, and assessing readiness and access to PR. time constraints. Provide help for current smokers
Living alone and a lack of social support have been who desire to quit. Good care and relationships with
cited as significantly impacting the ability to attend and providers improves the experience.
participate in pulmonary rehabilitation.17 Although
clinical data cannot, with certainty, predict which Declaration of Interest
patients are likely to decline or drop from treatment, Dr. Casaburi has served as a consultant for Boehringer
it can aid clinicians in improving participation and Ingelheim, Novartis, Regeneron and GlaxoSmithKline.
completion. He has received grants and served as a speaker for
Making a caring connection can make a difference. Boehringer Ingelheim, Novartis and AstraZeneca.
This can be achieved through an emphasis on Dr. Limberg is a consultant with Nonin. Dr. Vines is
improving the patients knowledge, skills and abilities an advisor for Boehringer Ingelheim and Bayer. He
to live well with COPD, actively listening and providing has served as a speaker for Teleflux Medical and has
an opportunity for questions. The initial contact needs received grants from Kimberly Clark and Aerogen.
to be meaningful and may need to be a call from the
ordering physician. The first face-to-face contact needs NOTE: To complete the CME post test for this article,
to convey compassion, caring, and that the provider refer to the original online version of the article at:
possesses the competencies that can help improve the www.journal.copdfoundation.org
patients breathing and movement.

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journal.copdfoundation.org JCOPDF 2016 Volume 3 Number 1 2016

484 COPD9USA Summary: Pulmonary Rehabilitation

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