A new perspective: pulmonary rehab at the Liverpool Heart and Chest Hospital

With COPD the theme for next year’s Physiotherapy Works programme, Louise Hunt reports on a new approach to care by the Pulmonary Rehabilitation service at the Liverpool Heart and Chest Hospital.

When in 2009 Joy Gana-Inatimi embarked upon a PhD in self-management strategies for chronic obstructive pulmonary disease (COPD) patients she had no idea her involvement in clinical research would have such a profound impact on her team, and on patient health outcomes. 
Over the years Joy’s steely focus on providing evidence-driven care has led to a new approach for the Pulmonary Rehabilitation (PR) service at the Liverpool Heart and Chest Hospital. Recently this has culminated in the service securing additional funding for expansion from the Liverpool Clinical Commissioning Group.
Explaining how the physiotherapy-led service has developed as a result of her research, Joy, who is the clinical lead in chest medicine and pulmonary rehabilitation, says the main change has been the fostering of a much greater understanding of the importance of data gathering and analysis for service development. 
As part of her doctorate training with the University of Central Lancashire (UCLAN), Joy has learnt data analysis skills and passed this knowledge of handling and interpreting data on to her team who now produce mid-year and yearly outcomes reports. These are proving invaluable in informing service-level agreements with commissioners.
‘The whole ethos of the team has changed, now we are all looking at health outcomes and evidence-based practice,’ she says.
The Liverpool PR programme is currently run over five community clinics and one based in the hospital. The team comprises chest physios, exercise physiologists and therapy assistants/support workers. ‘The Liverpool Heart and Chest Hospital is unique in having this skill mix within its PR 
service,’ says Joy.
As a result of Joy’s research-driven leadership, the whole team regularly meets to review health outcomes which enables them to fine tune their approach and develop their practice.
Technical instructor Donna Williams says she values these meetings as an opportunity to share information and discuss operational policies. 
‘Since Joy has been involved in research the meetings are more specific and a lot more constructive. Right now we are doing service mapping together and we’re thrashing out a lot, everybody has a voice,’ she says.
Team members have also taken on smaller research projects. Donna, for example, is involved in a project with UCLAN surveying the PR patients to see how patient information can be improved.
Evaluating and monitoring patient data is also enabling the team to gain a much better understanding of its patients and how to develop practice.

Developing a more flexible approach

The most significant development has been working with the commissioners to change the service from a traditional pulmonary rehab model to one that offers more flexibility. 
National Institute for Health and Care Excellence (NICE) guidance on COPD states that pulmonary rehab should be delivered for two sessions a week over eight weeks, but the evidence shows that attending all of these sessions can be a challenge for many COPD patients. 
‘Through research we found that North West services, which offered twice weekly rehab, had high levels of DNAs (did-not-attend) as patients were struggling to attend two sessions a week. We know that nationally completion rates for pulmonary rehab are low – historically around 35 per cent and, initially, patients were only deemed to have completed the programme if they had completed all ten sessions. 
‘But we were able to use our data to show that if a patient didn’t attend all the sessions there were still improvements in key health outcomes,’ she says.
The latest health outcomes report shows that as a result of attending the programme, patient functional capacity increased by 30.4 per cent post-PR; there was a 33.3 per cent improvement in respiratory disability and dyspnoea; and a 12.5 per cent improvement in anxiety and 33.3 per cent in depression. Patients also demonstrated a 21 per cent improvement in their understanding of COPD and how to manage their condition.
This evidence persuaded commissioners to redefine the completion criteria to health outcomes or goal orientated-based outcomes rather than an attendance-based criteria alone. 

Brief interventions count

‘Based on the evidence of our good health outcomes commissioners approved our recommendation to move to a brief interventions approach, which gives patients more flexibility.
‘Crucially, it means we have secured funding for patients who complete the whole programme and for patients requiring brief interventions or bespoke programmes of care that are more suitable to meeting the patient’s needs than traditional pulmonary rehab, and patients can choose which sessions they want to attend,’ explains Joy.
The PR programme is now delivered in once-a-week sessions over 10 weeks with increased access and patient choice.
In 2014-15, the Clinical Commissioning Group (CCG) granted additional funding which will pay for eight whole time equivalent clinical and clerical members of staff in addition to the current team. As a result two new community clinics were opened this month, doubling the capacity in the hospital clinic. A one-to-one clinic model is also being introduced across the board for patients who need additional support.
With the brief interventions model it is important to make every contact count, says Joy. The team has been indoctrinated in this ethos. ‘Every time they see a patient in a clinic they know it’s really important that the patient understands their condition, how to monitor their chest symptoms and how to use their medication,’ she says. 

Empowering patients

Exercise physiologist Tony Burns says the brief interventions approach is not only about treating the disease but supporting patients to live well. 
‘Before introducing this approach our main focus was on smoking cessation, but we weren’t identifying other factors for COPD patients, such as the importance of healthy eating. The [brief interventions] training has improved the quality of the information we provide and better empowers patients for behaviour change.’
The importance of taking ownership of their condition is drilled home to patients. Liverpool is the third worst area in the country in health outcomes for COPD, according to British Lung Foundation research. A contributing factor, Joy says, is that many patients do not understand their condition sufficiently, so do not attend annual reviews and spirometry tests. ‘We explain their condition to them, the importance of regular monitoring (self and medical) as this will enable patients to access other services to support them.’ 
She adds: ‘One of the biggest changes we see in patients over the course of the programme is that they finally grasp that they hold the key to managing their condition, a lot of patients haven’t fully understood that before.’
This was the case for 71-year-old Joan Tatlow, who has recently completed the programme after suffering an episode of double pneumonia and pleurisy. 
‘Before the programme I was terrified of leaving the house, but the staff explained everything to me and I’ve learnt quite a lot about my condition,’ she says.
‘It helped talking to other people who have gone through the same experience,’ says Joan. ‘Now I know I can go out – I’ve got a park opposite and a big dog that needs walking – but I needed to get the confidence to leave the house.’ fl

Inspiring research

Lizzie Grillo, chair of the Association of Chartered Physiotherapists in Respiratory Care (ACPRC), says the Liverpool PR programme is a good example of how to undertake compelling research into patient health outcomes.
‘We know that patients value a patient-centred approach, but articulating that to commissioners can be difficult to get right. 
‘You can use qualitative research to better understand patient experience and to work out what aspects of an intervention are helpful to a patient, but you need to make sure you evaluate this alongside quantitative data.’ 
Physiotherapists should not be afraid to use qualitative data. ‘It may be what’s missing from a lot of research’, she says, adding that ‘institutions appeared to be listening to it much more [than previously]’. 
Lizzie also hopes that the Liverpool example will inspire more junior physiotherapists to get involved in research. ‘There’s a real drop off when people finish university, but it needs to be engrained in their early careers. 
‘We [ACPRC] are aware that those who are just coming into research may be under supported unless they have champions in their workplace, so we are looking at ways to create more opportunities for them, such as through study days and getting articles published in the peer-reviewed journal.’ She also suggests contacting the ACPRC research champion, Fran Butler, who can advise members on how to progress research ideas, email: researchchampion@acprc.org.uk
Louise Hunt

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