A Sigh of Relief: Improving access to pulmonary rehabilitation

Lismore Base Hospital and Richmond Community and Allied Health have implemented new processes to assist individuals to access and complete pulmonary rehabilitation services following hospital admission for chronic obstructive pulmonary disease (COPD).

View a poster from the Centre for Healthcare Redesign graduation December 2021.

Aim

This redesign project aims to improve quality of life and health outcomes for people with chronic respiratory disease by optimising timely access to, and completion of, high-quality pulmonary rehabilitation programs.

Benefits

• Improved access to pulmonary rehabilitation programs
• Improved engagement with pulmonary rehabilitation programs
• Decreased disease burden for people with chronic respiratory disease
• Improved aerobic endurance for people with chronic respiratory disease
• Improved awareness of the benefits of pulmonary rehabilitation for clients and clinicians in Northern NSW Local Health District
• Standardisation of processes for programs which can be implemented across the local health district
• Decreased readmission rates following exacerbation COPD
• Improved client and staff satisfaction with the delivery of pulmonary rehabilitation services
• Imbedding data collection and evaluation processes into standard practice for pulmonary rehabilitation, allowing for longitudinal evaluation and ongoing service improvement.

Background

Pulmonary rehabilitation is a proven intervention that improves exercise tolerance and health related quality of life. It also reduces readmission following a hospital admission for exacerbation of COPD.¹ Pulmonary rehabilitation is highly recommended by peak bodies in Australia; however, there is no consensus on how programs should be delivered.^2-3

Historically in Lismore, pulmonary rehabilitation has only ever been delivered via face-to-face groups, run in a block model. This inadvertently creates a barrier for those without transport or other reasons for being unable to attend in person. It also leads to delays in terms of access, and service inefficiencies.

The COVID-19 pandemic has meant many changes to how we provide pulmonary rehabilitation services locally. Some of these changes have been beneficial and can be applied to how we deliver pulmonary rehabilitation in the future.

Implementation

Our project team used several methods to explore and understand the current situation including:

• sourcing available data on the numbers of clients hospitilised with COPD and those accessing pulmonary rehabilitation
• workshops and interviews with staff
• consumer interviews (current and previous).

Issues were collected, themed and prioritized. Solutions were then developed with stakeholders. Below are some of the themed issues and solutions that have been (or will be) implemented.

Increasing inpatient presence of pulmonary rehabilitation and making referral easier

It was identified that there were low referral numbers from the hospital because of a lack of awareness of the program or its benefits, and no dedicated referral pathway.

To improve this the team has developed and implemented several solutions:

• a dedicated eMR referral for pulmonary rehabilitation to allow for direct referral to the service by inpatient clinicians
• a new referral management process
• a new poster to advertise the program
• in reach by the program exercise physiologist to facilitate local awareness, referral to and engagement with the program.

In 2022 a further solution will be implemented:

• upskilling of ward nurses around COPD management and pulmonary rehabilitation.

New model of care for pulmonary rehabilitation

It was identified that running programs in a block fashion (everyone starting and stopping at the same time) could potentially delay access and be a barrier for people with transportation issues or who did not want to attend a centre-based group.

To address this the team:

• implemented a rolling program with regular scheduled assessments
• implemented (or continued to provide) a variety of options for people to attend including face-to-face, telephone and video conferencing.

Local guidelines for the provision of pulmonary rehabilitation

It was identified that we did not have local guidelines for the provision of Pulmonary Rehabilitation and did not collect data about program outcomes.

To help with this the team developed new guidelines for pulmonary rehabilitation and collect information that can be used to look at the direct benefits of the program.

Status

Implementation – The project is ready for implementation or is currently being implemented, piloted or tested

Dates

• Oct–Nov 2020: Planning for project and submission
• Dec 2020: Project approved
• Jan–Mar 2021: Development of project management plan
• Apr–May 2021: Exploration of local issues (diagnostics)
• Jun–Jul 2021: Development and prioritisation of local solutions
• Aug 2021: Development of implementation plan
• Sep–Nov 2021: Implementation including a trial period for the model of care
• Dec 2021: Evaluation of trial
• Jan–Dec 2022: 12-month implementation period followed by evaluation

Implementation sites

• Lismore Base Hospital
• Lismore Community Health

Partnerships

Centre for Healthcare Redesign

Evaluation

We are currently running a trial of our new model of care. Evaluation will include:

• number of referrals to the Lismore program from the hospital
• time to contact people following referral
• program outcome measures such as the six-minute walk test and COPD assessment test
• consumer feedback (patient reported experience measure)
• staff feedback (interviews).

Further evaluation at the end of 2022 will include looking at hospital readmission rates following the program.

Lessons learnt

• Implementing a project during a global pandemic is very challenging.
• Teamwork and communication are the foundations of success.
• Lack of easily available data is not a barrier (but does mean a lot of searching).
• Build on what is already working.

References

1. Alison JA, McKeough ZJ, Johnston K, et al. Australian and New Zealand Pulmonary Rehabilitation Guidelines. Respirology. 2017 May;22(4):800-819. DOI: 10.1111/resp.13025.
2. Lung Foundation Australia. Pulmonary rehabilitation overview [Internet]. Lung Foundation Australia; 2021 [cited 2021 Oct]. Available from: https://lungfoundation.com.au/health-professionals/clinical-information/pulmonary-rehabilitation
3. McCarthy B, Casey D, Devane D, et al. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2015 Feb 23;(2):CD003793. DOI: 10.1002/14651858.CD003793.pub3

Further reading

General information about pulmonary rehabilitation can be found at the Lung Foundation Australia website.

Contact

Rocco Mico
Respiratory Services Manager
Northern NSW Local Health District
Phone: 02 66207511
Rocco.Mico@health.nsw.gov.au