By Melinda Young
Silver Spring, MD-based Holy Cross Resource Center’s pulmonary rehabilitation program helps patients with COPD and other chronic lung conditions maintain their fitness and health post-rehabilitation care.
• Program goals include lowering hospitalization rates and ED visits.
• The program charges patients a small fee because it is not covered by insurance despite its economic benefits.
• People stay with the maintenance program for social benefits and camaraderie as well for health benefits.
A hospital-based pulmonary maintenance exercise program can help patients with chronic lung conditions improve their exercise tolerance and regain some lung function, while reducing readmissions, according to the authors of a recent study. The potential cost savings are significant as well.1
“The most significant finding, based on three years of data of 20 participants who met all of the criteria, was 71% reduction in nights spent in the hospital due to pulmonary problems,” says Kim Crilly, RN, MS, outpatient diabetes educator and coordinator of the pulmonary maintenance program at Holy Cross Resource Center in Silver Spring, MD. “We also had a 33% reduction in emergency department visits due to pulmonary conditions,” she adds.
The Holy Cross Health Pulmonary Maintenance Program provides patients supervised physical activity and education about disease management to patients with COPD or other chronic lung conditions. “We usually enroll 32 to 35 people at any time,” Crilly says. “We had 85 participants enrolled in the program during the three-year data period of April 2013 to the end of 2018.” Participants stay in the program an average of 2.3 years, she adds.
The program provides tangible physical benefits to patients, but it also offers social benefits, says Sarah McKechnie, MA, MES, manager of disease management services at Holy Cross Health. “It prevents social isolation,” she explains. “A lot of times, people with lung disease will stay in their homes and not go out much.”
Patients bond with each other, and show up for the exercise sessions mostly because they want to see their friends in the program, Crilly says.
The pulmonary maintenance program fills a gap between patients’ rehabilitation and living at home on their own.
“Patients get close to three months of rehab,” Crilly says. “Then they graduate, and there’s a big gap as far as whether they are going to be able to participate in community programs safely with oxygen or exercising on their own.”
Patients feel better after pulmonary rehab, but they need a maintenance program to help them stay healthy, Crilly notes.
“Resources after rehab are limited,” she says. “Patients need to continue to exercise after rehab to keep the benefits.”
The one drawback to the program is its cost. Although it saves healthcare dollars through reduced hospitalizations, it lacks insurance support, Crilly notes. “We are an out-of-pocket program right now, and that’s why we’d like it to get more attention,” she explains. “Maybe if nationwide programs could roll out more maintenance programs, they could be supported by insurance because of their cost savings.”
Without payer reimbursement, the program shifts a small fee to patients. They pay $70 per month for the twice-weekly, individual training and medical supervision, Crilly says.
This is how the Holy Cross Health’s pulmonary maintenance program works:
• Assign staff. Program staff include a registered nurse, respiratory therapist, exercise physiologist, administrative assistant, and program coordinator. “It’s overseen by medical professionals,” McKechnie notes.
“It’s critical to have such a knowledgeable staff because patients will plateau a little bit,” Crilly adds. “They’ll need to increase their exercise and duration.”
• Schedule patients. The program assigns patients one-hour time slots to exercise twice a week. Six patients will exercise each hour of the program. Each patient uses an individualized workout plan, Crilly says.
• Provide equipment. Pulmonary patients have access to a variety of exercise equipment and medical supplies. They rotate between three machines: a treadmill, a recombinant stair stepper, and an upper body ergometer, which patients use to strengthen and condition their upper bodies. All three provide a cardiovascular workout.
“It’s critical for people with lung conditions to increase their respiratory muscles,” Crilly says.
Other equipment and instruments include weights, exercise balls, oxygen concentrators, pulse oximeters, sphygmomanometers, stethoscopes, nasal cannulas, oxygen tubing, and an emergency oxygen tank.
• Set goals. A primary patient objective is to achieve at least 40 minutes of cardiovascular exercise each hour of class, Crilly says.
Program goals include:
- Maintain oxygen saturation at greater than 92% pre- and post-exercise;
- Maintain blood pressure at less than 139/89 mm/Hg pre- and post-exercise;
- Keep hospitalizations at less than two nights per quarter per participant;
- Keep ED visits below one per participant per quarter;
- Reduce overall number of hospital admissions per quarter to fewer than three;
- Decrease or maintain the yearly number of nights in the hospital, compared with the prior year;
- Decrease or maintain the yearly number of ED visits compared with the prior year.
• Assess patients. Two members of the pulmonary maintenance program staff check patients at each exercise session for their vital signs, including blood pressure, heart rate, and oxygen saturation.
“With this population, sometimes they arrive and need to get their oxygen saturation stabilized before exercising,” Crilly says. “During exercise, they may need breaks of one to two minutes for breathing, and they transfer from machine to machine between exercises.”
Patients are not on a heart monitor because to be eligible for the pulmonary maintenance program, they must be considered risk-free enough to not need a heart rate monitor, Crilly says.
• Assist with exercise. “We’re standing next to the individuals, and with every piece of equipment they’re on, we ask about their perceived trouble breathing,” Crilly says.
They monitor patients’ duration on cardiovascular equipment, their rating of perceived exertion, their miles per hour and grade.
“That’s how we determine how they’re doing,” Crilly explains. “If I look at quarterly data and see their duration or intensity is decreasing, but perceived duration is increasing, then that’s a sign the patient is failing in health, and this needs to be addressed.”
When there is a problem, staff can call the pulmonologist for help. The patient might need a new appointment, six-minute walk test, and another evaluation and pulmonary function test.
Patients who are in better physical condition might exercise for 50 minutes. Those with more severe lung disease or shortness of breath might struggle to put in 40 minutes of exercise, Crilly notes.
After patients finish their cardiovascular workout, they may use weights and resistance bands.
“Half of participants have time for bands and weights, and spend five to 10 minutes on that,” Crilly says. “Through our education session, we teach participants how to do resistance training at home. Our focus is cardiorespiratory endurance, so we save resistance for the end of the workout.”
• Motivate patients to participate. “We play music in the background and take requests,” Crilly says. “Our staff is amazing and upbeat, and we have fun parties and holiday parties.”
For example, Holy Cross Health holds a summer in February party to help combat winter depression among patients, Crilly says.
“We bring out leis, hula hoops, and seltzer water with umbrellas,” she adds. “It sounds silly, but they ask when the next party will be — they enjoy them so much.”
The parties are held once a quarter. Also, each month there is a morale booster activity. Every other month, there is a support group or information-sharing session.
“I invite everyone to come together, and we have a topic — maybe related to physical health or mental health,” Crilly says.
Crilly posts a flyer and sign-up sheet. “The respiratory therapist is amazing and will give educational tips,” she adds.
Participants form lasting friendships, and sometimes meet with other participants outside of the exercise classes, McKechnie says.
“The social piece is very important to people, and it keeps them going; they motivate each other,” McKechnie adds.
“We create positivity and support, and they thrive on that and on the dynamics with each other and their peers,” Crilly says.
• Keep participation open-ended. Patients stay in the program as long as they desire or can participate. Most leave because of a fall, a hospitalization, or death, Crilly says.
“Some of the other reasons people leave is that some participants just get tired,” she adds. “It can be absolutely exhausting to drive and get to class.”
A few others left to join a gym because they do not need to be monitored as closely.
“We have participants we can refer to other programs, like a Senior Fit, which is an evidence-based exercise program for seniors,” McKechnie says.
- Crilly K, McKechnie S. Improving outcomes, reducing readmissions: A case for pulmonary maintenance programs. CMSA Today 2019;7. Available at: http://bit.ly/38GS8f9.