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Starting a Pulmonary Rehabilitation Program

Pulmonary rehabilitation can help to improve the standard of care for patients with lung disease. But convincing administrators to loosen the hospital's purse strings and set up a program or to refine an existing one can be difficult. Drafting a formal proposal can tip the scales in your favor.

When writing a proposal to start a comprehensive pulmonary rehabilitation program, have you data and statistics ready. The actual proposal is only a few pages written in concise language, but you need to supply supporting documentation.

Begin by clearly stating the purpose for starting a program, such as:

• to reduce costs of lung disease re-hospitalizations

• to improve efficiency in chronic lung disease treatment

• to meet the demands of a high inpatient or outpatient referral volume

• to increase physician satisfaction with patient care

• to prepare for the increased volume of GOLD COPD Stage II - IV patients covered  in the Center for Medicare Services Pulmonary Rehabilitation National Coverage Decision.

Ask your institution for its support and commitment because comprehensive pulmonary rehabilitation is vital to its mission statement.

Opportunity statement

Next, craft an opportunity statement that explains the actions the hospital can take in response to the problem. This is a positive twist on the statement of purpose. For example, "An opportunity exists to meet the inpatient and outpatient volume demands and decrease the readmission rate for chronic lung disease. Currently, a system for comprehensive treatment of a pulmonary rehab patient does not exist. Standard of care cannot be delivered to this patient population."

Describe your proposed program's scope, volume, and target population. Is your patient base primarily COPD or restrictive lung disease, or is there a lung transplant program and pulmonary hypertension clinic that will refer patients to your program? Use the American Lung Association to find your county and city's lung disease statistics to clearly state the patient populations in your geographic area who would be served by the program. This can be very powerful information.

Mention the problems with the current system. Are physicians frustrated that there is not a pulmonary rehab program at the facility where they can refer patients? If you are redesigning your pulmonary rehab program, concisely state the current situation and the program's shortcomings.

Detail resources required

The next step is to project cost and revenue that would be added by this program, and set a timeline for implementation. Estimate salaries for a medical director, a clinical manager, and staff trained in this skilled level of therapy, or funding needs to train existing employees.


    Know the components of a comprehensive program: assessment, therapeutic exercise, education, psychosocial intervention, and long-term adherence.

    Understand and articulate your hospital's admission and discharge rates for chronic lung disease.

    Be familiar with the CMS National Coverage Policy for pulmonary rehabilitation for skilled level of care, ICD-9 Diagnosis and reimbursement guidelines, and the Medicare Administrative Contractor's (MAC) Local Coverage Policy for pulmonary rehab and understanding of the skilled level of care, documentation, and reimbursement criteria.

    Consider where the pulmonary rehab program will be located in the medical center (in the respiratory care services department, in physical medicine, etc.

    Have strong medical direction required for pulmonary rehabilitation.

    Understand the physician referral source and volume of referrals, and how to market your pulmonary program to them.

    Know the evidence-based literature resources that should be in every pulmonary rehabilitation policy and procedure manual.

    Emphasize to administration that pulmonary rehab develops patient relationships over extended years with high program loyalty and longevity.

    Contact your state affiliate of the American Association of Cardiovascular and Pulmonary Rehabilitation and the American Association of Respiratory Care, and join the national association and your state chapter. This networking is crucial to know what is happening on the reimbursement front and how to develop your program's documentation to meet CMS' expectations.

Detail what additional resources are required including equipment, space, and supplies. The facility should have adequate space for an educational classroom, exercise facility, storage of daily and emergency supplies, and record keeping space to cover HIPPA and confidentially issues. Considerations also should include the facility's handicap parking and accessibility; environmental issues such as optimal light, temperature and ventilation; and access to restrooms and to water for drinking and washing hands.

Some pulmonary rehab programs are able to share space with an existing cardiac rehabilitation or physical

medicine programs. But the pulmonary rehab center will also need an oxygen source, delivery apparatus, and monitoring devices for oxygen saturation. The latest edition of the AACVPR National PR Guidelines is a critical resource for this information.

Make a recommendation

Be sure to highlight the opportunity for pulmonary rehabilitation to contribute to the cost reduction of COPD admissions at your hospital. Look at the hospital's chronic lung disease readmission rates and physician and patient satisfaction data. Consider the opportunity for revenue offset by reducing the pulmonary admission length of stay and readmission rates from the current standard of care. Can you project when the cost savings should be realized and how this data can be tracked? 

Finally the proposal should clearly state that your recommendation is to move forward with implementation of a comprehensive pulmonary rehab program because of the favorable outcomes and benefits associated with it. Clearly state that you are asking for institutional support, commitment, and approval.

Once you have a draft of your proposal, consider showing it to other pulmonary rehabilitation professionals who have successfully started and maintained a program, and ask them to point out areas that need to be improved. They also can prepare you for the possible reactions and questions you will receive from administrators when your proposal reaches their desks.

Gerilynn L. Connors, RRT, BS, FAACVPR, FAARC, is clinical manager of pulmonary rehabilitation at Inova Fairfax Hospital, Falls Church, Va.


ACCP/AACVPR Pulmonary Rehabilitation Guidelines Panel. Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Guidelines. Chest 2007; 131.

American Thoracic Society and the European Respiratory Society Statement on Pulmonary Rehabilitation. Am J Respir Crit Care Med; 2006.

American Association of Cardiovascular and Pulmonary Rehabilitation: Guidelines for pulmonary rehabilitation programs, 4th Edition, Champaign, Ill, 2004, Human Kinetics.

Ries AL, Bauldoff GS, Carlin BW, et al: Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines. Chest 2007; 131: 4-42

AARC Clinical Practice Guidelines Pulmonary Rehabilitation. Respir Care 2002;47, 617-25.

Nici L, Donner C, Wouters E, et al: American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation, Am J Respir Crit Care Med 2006;173:1390-1413

Nici L, Limberg T, Hilling L, Clinical competency guidelines for pulmonary rehabilitation professionals. AACVPR Position Statement. J Cardiopulm. Rehabil. 2007;27:355-8.

Executive Summary: Global Strategy for the Diagnosis, Management, and Prevention of COPD Revised 2006. Peer-reviewed summary of GOLD recommendations for the diagnosis, management, and prevention of COPD Am J Respir Crit Care Med 2007;176:532-55.

Pulmonary Rehabilitation Guidelines to Success: 4th Edition, Hodgkin, Celli, Connors Editor, Elsevier 2009.

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