Tackling health inequity: diversifying the community rehabilitation offer for people post-chronic obstructive pulmonary disease (COPD) exacerbation in Bridgend.
Project overview, including who was involved in the project
Frequent exacerbations for people with COPD, alongside complex co-morbidity, can significantly impact function, physical ability and health status. The COPD Team provides an integrated rehabilitation approach following exacerbation to optimise recovery, improve quality of life (QOL) and reduce exacerbation risk for long-term health benefit.Comprehensive assessment of patients with COPD post-exacerbation frequently identifies the need for exercise, however due to significant symptom burden, high prevalence of malnutrition, and frailty and falls risk, an alternative to the current home exercise programme (HEP) offer was required. The objective was to diversify home rehabilitation options to improve equity and access for patients with COPD to optimise outcomes and reduce exacerbation risk.
A service development project was undertaken using a Plan-Do-Study-Act (PDSA) approach reviewing the challenges and barriers to uptake of HEP post-exacerbation. Three additional exercise options were developed based on the gaps identified:
1.Functional HEP (FHEP) - duration and activity individualised with the aim of achieving an agreed functional goal.
2.Low body mass index (BMI) HEP supervised sessions twice a week for 6 weeks for patients with BMI <20kg/m2 with dietetic support and regular weight monitoring. Exercises followed guidelines for a 'low resistance, high repetitions' programme to reduce risk of fat-free mass loss.
3.Balance-focused HEP - 3 supervised sessions of balance exercises over 6 weeks where balance impairment was identified using the 4-stage balance test.
Evidence-based, reliable and valid physical and QOL outcome measures (OMs) were chosen for each programme. A staggered approach for programme introduction occurred from July 2023 to September 2024.
Who was involved in this work/project?
The Swansea Bay University Health Board Bridgend COPD Team comprises a multi-disciplinary team (MDT) of physiotherapists, nurses, occupational therapist, technician and dietitian providing community intervention for those with the highest disease severity and symptom burden. The service provides exacerbation support and self-management education with the aim of admission avoidance and early supported discharge.
Project outcomes/impact
There is now a home rehabilitation option for 100% of patients’ post-exacerbation. 31 patients were referred for an alternative programme with an uptake rate of 77%.The following outcomes were achieved:
1/ FHEP - 79% of patients achieved their goal measured using the goal attainment scale. 21% continue to receive rehabilitation currently.
2/ Low BMI HEP - 100% improved their rating of perceived exertion scale (Borg), number of sit to stands, timed up and go, grip strength and EuroQol 5-Dimension 5-Level OM (EQ-5D-5L). 50% of patients improved their self-rated health visual analogue score (VAS) and COPD Assessment Test (CAT) score.
3/ Balance HEP - 100% of patients improved their balance as assessed with the 4-stage balance test. 43% achieved the final stage where none had achieved it at pre-assessment.
There were no adverse events identified with 100% patient and clinician satisfaction reported.
Diversifying our offer provided individualised, equitable and accessible rehabilitation to all patients. This enabled 77% of patients to undertake rehabilitation that would otherwise not have accessed any form of exercise. Due to positive outcomes across all programmes, these alternative rehabilitation options are now part of standard practice. Ongoing development will include use of QOL OMs across all programmes to ensure interventions are associated with meaningful individual improvement.
This project has highlighted the importance of adapting existing approaches so that even the most complex and debilitated COPD patients can access safe and effective community rehabilitation, overcoming barriers and reducing healthcare inequities. This has the potential to reduce the impact of the negative consequences of COPD, reduce exacerbation rate and a reduction in healthcare utilisation.