Pulmonary rehabilitation – providing integrated care to patients with chronic obstructive pulmonary disease

Introduction: Chronic obstructive pulmonary disease (COPD) is a chronic lung disease that results in increasing breathlessness in addition to systemic effects on the body and has significant impact on mortality and morbidity. Context: Pulmonary rehabilitation is recognised as an important facet of COPD management and, based on high level of evidence has been shown to decrease dyspnoea, decrease anxiety and depression, increase exercise tolerance and reduce hospitalisations and health care costs. Pulmonary rehabilitation is defined as “a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies, which include, but are not limited to, exercise training, education and behaviour change, designed to improve the physical and emotional condition of people with chronic respiratory disease and to promote the long term adherence of health enhancing behaviours”2. Target population: In Australia, it is estimated that almost 13% or one in seven Australians aged 40 years or over are affected by COPD1 . Change implemented: Western Sydney Local Health District has developed an innovative pulmonary rehabilitation service (Respiratory Ambulatory Care) that provides integrated care to patients with COPD across the disease trajectory within a pulmonary rehabilitation program. Respiratory Ambulatory Care recognise that patients with COPD often have a range of unmet health needs due to the complexity of their disease and comorbidities. Patients referred to Respiratory Ambulatory Care undergo a comprehensive holistic multidisciplinary assessment and based on clinical findings, are linked into a range of services including clinical psychology, dietetics, speech pathology, home monitoring and support / outreach, smoking cessation, single point of contact for advice during acute exacerbations (Respiratory Hotline) and end of life support. Referrals are coordinated and followed up during the rehabilitation program to ensure patients are successfully linked into required services. Case conferences and care planning is arranged by staff to ensure all members of the patient’s health care team are invited to contribute to the patient’s care. World Congress on Integrated Care 2014, Sydney, November 23-26, 2014. International Journal of Integrated Care – Volume 14, 8 December – URN:NBN:NL:UI:10-1-116596– http://www.ijic.org/ Patients are supported in behaviour change through coaching and self-management support and are encouraged to become active participants in their healthcare decision-making. Communication between services is assisted by Respiratory Ambulatory Care’s use of the electronic medical record. Other providers within the local health district can access Respiratory Ambulatory Care’s assessments to reduce duplication of tests. General practitioners and non-hospital based services are faxed results of clinical assessment and progress within 24 hours of completion. Outcomes: A retrospective chart review of 141 patients who had participated in the pulmonary rehabilitation program revealed an improvement of health related quality of life (as measured by the St George Respiratory Questionnaire) of 7± 11 unit points (minimal clinical important difference (MCID) is 4 units) and an improvement in functional capacity as measured by 6 minute walk test of 58 ± 68 m (MCID 30m). Pulmonary rehabilitation services play a critical role in care integration for patients with COPD. Similar chronic disease rehabilitation programs could easily provide similar services ensuring patients care is coordinated, seamless and integrated.

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