Boone County Health Center Pulmonary Rehabilitation Program
- Need: Evidenced-based intervention to improve function and quality of life for patients with chronic obstructive pulmonary disease and other chronic lower respiratory conditions.
- Intervention: Pulmonary rehabilitation program implementation in 1989.
- Results: Compared to a national average of only about 3% of referred Medicare beneficiaries actually enrolling in pulmonary rehabilitation, 60% of the program's referred patients enroll. Averaging around 15 patients/year completing the program, a large combined cardiac and pulmonary rehabilitation maintenance population averages 8,000 visits/year.
Cardiovascular and lower respiratory conditions are
leading causes of death in rural America. For Nebraskans
with chronic obstructive pulmonary disease (COPD), a 2011
Centers for Disease Control and Prevention survey
revealed that nearly 60% of the state's respondents with
COPD reported having their activity limited by the
condition and about 20% reported experiencing poor mental
health for more than 2 weeks of each month. A
long-standing known treatment beneficial for these
condition-related issues is pulmonary rehabilitation,
referred to as PR.
Boone County Health
Center (BCHC), Albion, Nebraska, has offered PR to
the people in its service area with chronic obstructive
pulmonary disease (COPD) and other respiratory conditions
for over 30 years. The program began in 1986 when a
member of the hospital's nursing staff observed a
tertiary care center's cardiac rehabilitation (CR)
program. Despite the center's concern that CR could not
be delivered in a rural Critical Access Hospital (CAH),
CR was started in 1987 eliminating patients' 270 mile
round-trip travel burden. Immediate success of the CR
program led to the addition of pulmonary rehabilitation
(PR) in 1989.
has about a 50-mile service radius and serves as a hub
for 4 rural health clinics (RHCs) located about 25 miles
in all directions from BCHC. Care is delivered by 8
physicians and 8 advanced practice providers. As
suggested by a 2019 academic
review on PR services in rural hospitals, the BCHC
website lists PR program under its services. Providers
order PR using order sets available in the clinic- and
hospital-based electric health record (EHR).
The program is located on
the hospital campus in a dedicated 4,000 square foot
rehabilitation center, built as a result of a private
donation. The space also houses cardiac rehabilitation
and physical and occupational therapy services. Medical
directorship and supervising provider — the latter as the
mandatory on-site provider for the program — roles are
filled by the local primary care physicians.
- Participants must meet GOLD
criteria guidelines: moderate, severe, or very severe
COPD as determined by spirometry performed either at BCHC
the hospital or at the visiting pulmonologist office, who
travels from another Nebraska community, a round trip
distance of nearly 200 miles.
PR program services follow current Centers
for Medicare and Medicaid Services (CMS) statuary
requirements and include these specific elements:
- Individualized treatment plan
- Goal setting
- Exercise component
- Breathing techniques
- Nutrition, psychosocial needs
- Medication adherence
- Oxygen use and needs
- Balance training
- Address other core components: diabetes, tobacco use,
weight management, etc.
- Exercise equipment: Treadmills, stationary bicycle,
recumbent stepper, ellipticals, Arc trainer recumbent
bicycle, weight machines
- Cardiopulmonary resuscitation equipment, including
Hospital-based staff available to PR patients as needed:
- Social worker
- Mental health staff
- Respiratory therapist
- Physicians serving and medical directors and direct
Anticipated new prevention and education services:
Education is integral to PR and the BCHC PR staff
recognizes the value of prevention education in
preventing worsening of any chronic lower respiratory
conditions. Smoking cessation is included, but 25% of
COPD patients have not smoked and experts point to other
risk factors present in rural areas, such as dust, mold,
and chemical exposure as contributing to worsening
chronic lung conditions as well as causing them. Since a
high percentage of the people in the BCHC service area
have a generational involvement in agribusiness, the
organization is developing an education program for
proper respiratory personal protective equipment.
Though the total number of area's
eligible patients can't be assessed, the total number of
identified patients can, as well as the number of
patients that are referred and actually enroll: 95% of
those identified are referred and 60% of patients
referred actually enroll.
About 15 patients per year complete the PR program and
average about 30% of the total new patient load of
cardiac and pulmonary rehabilitation. The program
completion rate is high with graduates joining the large
maintenance population that averages 8,000 visits/year.
- Accommodating the busy schedules of farmers and
ranchers in the hospital's service area population.
- Early identification of patients with lung disease.
- Acceptance that PR is:
- More than exercise
- the use of modern equipment and evidence-based
program elements that have proven benefits in lung
- It's important to start new programs with the premise
that pulmonary rehab is not a "faux" cardiac
- Pulmonary patients are unique and have their own set
of physical and behavioral health problems which requires
individualization of the participant's program.
- Focus on provider education using supporting data on
the benefits of PR on quality of life and longevity.
- Be prepared for increased time needs of the PR
patient since they require breathing coaching and
recovery rest periods.
Gayla Oakley RN, CCRP, MAACVPR, Director of Cardiology Services and Prevention
Boone County Health Center
Agricultural health and safety
Chronic disease management
Chronic respiratory conditions
Critical Access Hospitals
June 10, 2021
Date updated or reviewed
June 8, 2022
Suggested citation: Rural Health Information Hub,
Boone County Health Center Pulmonary Rehabilitation Program [online]. Rural Health Information Hub. Available at:
[Accessed 7 February 2023]
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