The Greenwich Pulmonary Rehabilitation Programme: a virtual delivery model & a QI project

Purpose

The Greenwich Pulmonary Rehabilitation (PR) Service consists of 0.1 WTE team lead, 1.0 WTE band 6 split between 2 part time staff, a fixed term 3 month contract band 5 physiotherapist and 1.0 WTE rehab assistant.

The driver behind the project was to address the issue of the suspension of our face to face supervised PR classes (4 sessions per week at local leisure centres) during the COVID pandemic. With a mounting waiting list and an expectation that we would not be able to return to business as usual, we had to adapt.

Our primary objective was to design a programme that was effective, safe and that patients would enjoy.

A secondary objective alongside the Oxleas QI team was to increase patient completion rates over a 3 year period.

Current completion rates for the Greenwich Pulmonary Rehab programme was low at 40%.

The end point of the project was to be able to confidently offer increased patient choice on how to access PR.

There is an ongoing national challenge to manage patient drop out rates, which are multifactorial in nature. The redesign and delivery of a virtual programme could address problems such as: difficulties travelling to the class, poor weather conditions and psychological challenges where patients feel unable to leave their home to attend.

GAD-7
No. patients with reduction in their anxiety scores = 61%
PHQ-9
No. patients with reduction in their depression scores = 61%
Feedback
“I feel less anxious to leave the house”

“It’s easier to have my family/carer join me when exercising”

“It’s easier to carry on with home exercise”

Approach

Aim

To assess the appetite for virtual PR, and establish robust pathways to assess and mitigate risk when managing patients in a new virtual capacity.

 

Method

Telephone 120+  patients to discuss options: be assessed for virtual PR or wait for supervised PR.

The redesign of the PR SOP and other changes included:

  • Peer feedback from cardiac rehab class: sharing of risk assessments and learning
  • Staff training on the use of Microsoft Teams
  • Creation of new risk assessment and risk mitigation plans
  • Redesign pathway from triage to enrolment
  • Trial pilot session of virtual PR- including patients in the design and delivery of the exercise component
  • Promotion of the new service within Primary and Secondary Care
  • Use of a home hazard assessment tool and falls risk screening tool
  • The review and use of the sit to stand in 1 minute test as a functional exercise outcome measure
  • The acquisition and use of 60 pulse oximeters
  • Redesign of the delivery of remote exercise including training the rehab assistant
  • The incorporation of myCOPD app to support self management and its use as an exit strategy for exercise
  • Creation of the QI project
  • The training of patients in a 1:1 capacity to improve their IT literacy and confidence  
  • A phased reintroduction of the education component using the wider MDT
  • Collation of outcome measures
  • Collation of patient attendance and completion data
  • Redesign of a the patient experience survey and collation of quality data

 

QI Aim

To increase completion rates for the Greenwich Pulmonary Rehabilitation programme participants to 50% by December 2021, 60% by December 2022 and 70% by December 2023, aided by virtual PR as an alternative to the traditional supervised programme.

The Institute for Healthcare Improvement (IHI) model for improvement methodology is being used. We have explored the problem, developed an aim, collected baseline data and continue to collect data throughout the project. The project team continues to brainstorm change ideas which are being tested using PDSA cycles.

 

Service user involvement

A current information video for health care professionals and patients was produced in 2012 to promote, educate and inspire patients to engage with PR.

The plan is to now replicate this video using patient experience and motivational testimonials to support health care professionals understand the role of virtual PR and help patients to engage with this new model.

 

Addressing IT health inequalities

An audit identified 5/37 patients who did not have access to a tablet/computer/smart phone who were appropriate for a loan of a tablet. 2 tablets at £65 each will be available to loan to patients every 8 weeks to address an IT health inequality. This is due to be trialled in the coming weeks.

Outcomes

Outcome measures:

sit to stand in 1 minute, PHQ-9 , GAD-7, CQC, MRC

 

Data collected:

No. of patients assessed, enrolled & completed PR

Patient experience: collected via SMART survey

 

Preliminary Results: 51 patients enrolled. 26 completers, 6  partial completers, 10 non starters, 9 in programme

 

Sit to stand in 1 minute (MCID: 3).

Patients who completed 12 sessions (full programme) mean improvement of 5.75

 

GAD-7

No. patients with reduction in their anxiety  scores = 61%

 

PHQ-9

No. patients with reduction in their depression scores = 61%

 

Completion rates: 61%

 

Feedback

“I feel less anxious to leave the house”

“It’s easier to have my family/carer join me when exercising”

“It’s easier to carry on with home exercise”

Cost and savings

Only additional cost: HP laptop @ £700

 

Cost savings:

Travel/parking @ £150 pcm.

Refreshments @ £120 pa

Room hire- return to leisure centre (approx. £8000 pa)

Implications

Reflection:

To date we have had no adverse events.

Changes made so far as part of the QI project to improve completion rates:

  • Introduction of text reminders to attend sessions
  • Increased 1:1 time spent supporting patients practicing the use of technology
  • The offer of 1:1 telephone calls with the long term condition clinical psychologist to screen for barriers and enablers for patients with higher levels of anxiety/depression who struggle to commit to the classes
  • The routine sharing of results of patient outcome data to class participants  
  • Redesign of the user feedback survey
  • Plans to record a video on virtual PR

 

Current data suggests that the new virtual model is a success. Outcome data is looking comparable to the face to face programme results.

With a menu based option of care, we could confidently offer greater choice for the provision of pulmonary rehab as a therapeutic MDT intervention for patients with a chronic lung condition.

Top three learning points

  1. Team communication is vital.
  2. Do not underestimate the ability of the older generation to learn new IT skills!
  3. Being flexible and keeping an open mind will help drive a project forward.

Fund acknowledgements

Work unfunded.

Additional notes

For further information about this work please contact Helen Jefford.