By Anna Horner | News & Views

Pulmonary rehabilitation (PR) programs may find it difficult to recruit and retain patients for several reasons, both at the patient and program levels, but having an engaging PR team and an additional support person in the role of a “PR Champion” can go a long way toward boosting enrollment and completion rates, according to Carolyn G. Garcia, MD, MS, interim chief of Baystate Health’s Division of Pulmonary and Critical Care Medicine. These patient navigators can help PR teams overcome patient-level factors, such as lack of transportation and self-motivation, and implement program-level innovations to make PR programs more accessible.

PR Champions Help Improve Patient Outcomes

“PR Champion” is a term used for any healthcare worker who essentially promotes PR in a healthcare system, Dr. Garcia explains. “It’s a designation made for someone who has a vested interest in PR and promotes enrollment and participation and can provide education about PR to other clinicians and patients,” she says. “There are no specific credentials for this individual. It’s usually someone like a respiratory therapist who promotes PR to patients and other medical professionals and provides education about PR programs. They often have another role, such as a provider or a nurse, and their roles may overlap with Nurse Navigators, who also perform patient outreach and care coordination.”

Although adding a dedicated “PR Champion” requires additional resources — which may not necessarily be monetary but simply an investment in time for training — Dr. Garcia says, “These individuals not only can promote the benefits of pulmonary rehab for patients but also serve as the point person to follow up with patients who don't show up for a session, determine why they missed a particular class, and identify strategies to bridge gaps that the patient may have that's making it harder for them to participate in PR.”

Overcoming Patient-Level Barriers to PR

For patients who lack reliable transportation, Dr. Garcia says, “PR teams should engage in creative thinking to identify resources for transportation benefits, such as vouchers for ride-sharing or public transportation, which have been shown to help increase the likelihood of patients attending PR sessions.” She says PR teams also should leverage their clinical expertise, especially when patients have multiple conditions. “Being aware of a patient's medical comorbidities allows them to guide conversations and offer support to patients while they're exercising and participating in the sessions to promote the likelihood of them coming back.”

Regarding self-motivation, Dr. Garcia notes that “if patients don't feel they're getting a benefit from PR, they're — not surprisingly — less likely to participate. However, what's been shown in the medical literature is that the communication, messaging, and support from PR staff is incredibly powerful. Simply being aware of the patient’s perception of benefit can inform how the PR team engages with patients and really helps them realize the progress they've made and will continue to make if they complete the program.”

Proactive Program-Level Approach Is Key to Patient Engagement

On the program level, Dr. Garcia says highly successful PR programs across the country implement proactive strategies to identify patients with COPD who would benefit from PR (Spitzer et al., 2023). This could involve identifying all patients hospitalized for COPD exacerbation at a particular hospital and having the PR team visit them in the hospital, talk to them about PR, and invite them to participate. “Such a proactive approach helps capture patients who would benefit from PR and start the engagement process to motivate them to attend PR sessions,” she says. “Other program-level innovations could involve meeting patients where they are, offering morning, afternoon sessions, and evening sessions to accommodate patients’ schedules.”

“Our PR team is very dynamic and very fun,” Dr. Garcia adds. “Our PR gym is co-located within our pulmonary clinic, which is another program-level innovation that might help if reasonable, so patients can see me in the clinic, and as they're walking out, they see the gym at the end of the hallway, playing ‘80s rock with everyone having a great time. It’s almost like a subliminal message: Look how much fun they’re having; you should come and have fun here, too. Look how much they’re exercising; you can do that, too.”

She notes that the PR team is good at reaching out to patients who miss a session. Because they are nice, kind people, she adds, “I feel like patients can connect with them and be transparent about not feeling well or feeling up to attending.” With these patients, Dr. Garcia says there is an opportunity to re-engage them, and the team “tries to get them to feel like part of a group, and that when they're not there, they're missed, which can be really helpful.”

A Low-Risk but Impactful Intervention

Dr. Garcia attributes the substantial improvements she has observed among patients, in part, to the work of the PR team to boost engagement. “I've had patients who when they started could only exercise for 10 minutes before they had to stop. And at the end of the program, I would see greater than 60 minutes of exercise time, which is incredible,” she says. “I think what our program does well is engage patients, and the gym connected to the clinic is very helpful because it sends a message that this is part of managing your chronic respiratory disease. It's really cool to see it work and to see my own patients come back after they've completed phase two and say that they want to go back because they liked it so much.”

Dr. Garcia emphasizes that pulmonary rehab is a low-risk but impactful intervention. “It’s important for us in this specialty to get the word out that PR benefits everyone,” she says. “There is minimal to no risk associated with PR, and it is such an effective intervention that can really impact the quality of life of patients with chronic respiratory disease.”

Reference

Spitzer KA, Stefan MS, Priya A, Pack QR, Pekow PS, Lagu T, Mazor K, Pinto-Plata VM, Bradley K, Heineman B, ZuWallack RL, Lindenauer PK. Promoting Participation in Pulmonary Rehabilitation after Hospitalization for Chronic Obstructive Pulmonary Disease, Strategies of Top-performing Systems: A Qualitative Study. Annals of the American Thoracic Society. 2023 Apr;20(4):532-538. doi: 10.1513/AnnalsATS.202203-237OC. PMID: 36449407; PMCID: PMC10112402.