Best practice for PR
Following the national COPD audit, this is an overview of key points to consider in commissioning pulmonary rehabilitation (PR)
The national COPD audit in 2018 recommended 3 quality improvement priorities for PR:
- Reduce waiting times for enrolment to PR. Set a target of 85% of patients enrolled within 90 days.
- Exercise assessments to meet recommended technical (BTS and quality) standards. This includes practice walks and using appropriate walking course lengths.
- Programmes to have patient completion rates of 70% or more.
PR best practice checklist
Access to PR
- Cater for your patient population
- Have a robust referral pathway
- Train staff to refer patients
- Give priority to PR
Quality of PR
- Involve patients in the design and delivery of PR
- Give patients information about the benefits of PR
- Give patients a self-management plan after PR
Take into account the demand and geography in your area. Consider:
- How many people need PR?
- Where is the best place for PR to be held to meet the need?
- Is there good transport and access to venues in these locations?
- Will you provide a rolling or a cohort programme?
The Chartered Society of Physiotherapists has an economic modelling tool to help you maximise the number of eligible COPD patients doing PR. Input your local data to calculate the cost of delivering a service and show costs savings.
- Ask GP practices to use a data search to find eligible patients. For example, search COPD and MRC 3+. Flag them to be referred to PR at their next review.
- Promote your programmes simply and clearly to patients. Consider lung conditions, gender, ethnicity and cultural background in deciding key messages.
- Tailor the PR education to the needs of patients. Does your patient have COPD or IPF? Are they are male or female? Are they from an ethnic minority?
Have a simple referral process - such as a single electronic form to be completed by relevant health care professionals
- Review where your referrals come from – GP practices, community care or secondary care?
- Incentivise referrals. For example, include a CQUIN payment framework to encourage providers to prioritise PR as a health care intervention.
- Include patients recently discharged from hospital with a COPD exacerbation. Include PR in the respiratory discharge bundle from respiratory wards and emergency departments and acute admission units.
To promote PR with confidence and authority, all health care staff who refer must understand the benefits of PR, what it covers and where it’s held locally.
- Encourage health care staff, such as GPs and practice nurses, to visit a local class to find out first-hand what happens.
- Use motivational interviewing techniques to help guide and support patients – especially if they’re reluctant or unwilling - to understand the benefits of PR for them.
- Give patients the option of a referral later if the current timing is not appropriate or convenient.
PR should be at the heart of a robust integrated community respiratory system. This will ensure provision meets local needs and reflects is the population, with adequate funding to drive improvements in quality and patient outcomes.
- Give PR priority in integrated care system planning.
- Involve all partners - GP practices, hospitals, community services, social services and the voluntary sector.
The 2018 audit recommended patients referred for PR should be enrolled within 90 days. Work with GP practices, community and secondary care providers to improve waiting times and access.
- Make sure there are locally agreed referral pathways, standardised referral templates and appropriate read codes in GP practices.
- Investigate any variation in GP referrals.
- Consider support and incentives to help practices referring fewer patients.
Use your local data from the national COPD audit to understand what’s going well and where PR can be improved.
- Commissioners and PR providers should work together to review quality.
- Both should commit to the 3 quality improvements recommended by the 2018 audit.
- Ask your PR provider to join the RCP PR services accreditation scheme (PRSAS).
The Royal College of Physicians pulmonary rehabilitation services accreditation scheme supports the delivery of best quality care by ensuring providers deliver services that meet the BTS clinical guidelines (2013) (PDF, 928KB). It helps you to be sure that the PR you commission is clinically effective, person-centred and cost effective. The scheme has an annual fee which includes access to training days, an online web tool to support self-assessment and action planning, and access to a knowledge management system which contains examples best practice from accredited services.
Non-completion of PR is a challenge for all providers. Understanding patients’ reasons for not completing a programme is key to identifying solutions.
Issues may vary from the practical - like getting to venues, availability of car parking etc. to lack of motivation, such as not understanding of the benefits, not feeling supported at the sessions.
- Ask for, and listen to, the views of your patients. They are best placed to give frank and honest views on the service they receive and possible solutions.
Many patients do not understand what PR is or how it can help them. Many don’t want to think about exercising while they are unwell and breathless. To reassure them and encourage them to attend and complete a course, tailored information can help before, during and after a PR course.
- Health care professionals can use the information in their conversations about PR.
- Encourage patients to share this information with their family and friends.
BLF has resources explaining what PR is, its benefits and about keeping active more generally. Have a look at our
There is emerging evidence that post-PR exercise maintenance classes provide health benefits to patients and help reduce health care costs such as admissions to hospital.
- Give patients information to help them continue exercising after PR
- Provide maintenance exercise classes for patients who’ve recently completed PR
- Allow patients to repeat PR a year after their first course
- Encourage your PR provider to link with local physical activity providers to signpost suitable activities, such as BLF Active classes or local authority exercise schemes.
- Encourage patients to stay active. This could include walking, using an exercise DVD at home or more formal activities such as organised walking groups, singing for lung health classes, tai chi movements for wellbeing or other community activities.