Boone County Health Center Pulmonary Rehabilitation Program

Description

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.

The hospital 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.

Services offered

Program requirements:

• 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
• Education
• 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.

Equipment:

• Exercise equipment: Treadmills, stationary bicycle, recumbent stepper, ellipticals, Arc trainer recumbent bicycle, weight machines
• Oxygen
• Cardiopulmonary resuscitation equipment, including defibrillator

Dedicated staff:

• Exercise physiologist
• Registered nurses
• Community health coordinator
• Receptionist

Hospital-based staff available to PR patients as needed:

• Dietician
• Social worker
• Pharmacist
• Mental health staff
• Respiratory therapist
• Physicians serving and medical directors and direct supervisors

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.

Results

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.

• Note: These results can be compared to national data showing nearly 70% of primary care physicians were aware of PR availability, yet only about 40% routinely prescribed PR and that of Medicare beneficiaries referred to PR, only about 3% 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.

Challenges

• 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 disease

Replication

• It's important to start new programs with the premise that pulmonary rehab is not a "faux" cardiac rehabilitation program.
• 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.

Contact Information

Gayla Oakley RN, CCRP, MAACVPR, Director of Cardiology Services and Prevention
Boone County Health Center
402.395.3149
goakley@boonecohealth.org