Good afternoon and thank you very much for the opportunity to be here today and to talk to you on this topic. Physical activity in chronic respiratory diseases is very problematic. We know that in most of our patients, physical activity levels are low, and physical activity is a predictor of many poor outcomes. For example, in COPD, we know low activity levels are associated with hospitalisations, or cause mortality, poorer quality of life, as well as development of comorbidities. Therefore, it's very important that we consider interventions to target physical activity to promote increased levels of activity. However, this is very challenging, as I will cover in my presentation today, and you'll hear across the presentations today, that targeting or changing physical activity is very challenging. As you know, and many people will hear from the pulmonary rehabilitation clinicians, that exercise training alone is very difficult to change physical activity, and typically that we don't see changes in physical activity from exercise training alone. And therefore, behavioural interventions show great promise, whether they're in combination with exercise training or done in isolation, in terms of changing activity levels. This will be well known to many of you in the audience, but I'd like to talk a little bit about physical activity and the factors that influence them before we get into interventions that may change it. The most common definition used for physical activity is any bodily movement produced by the skeletal muscles, resulting in an increase in energy expenditure of the body. A definition used by patients that I really, really love is any lifestyle activity, including walking, gardening, and housework as part of their daily routine. And as will be well known to you, physical activity is a different construct to exercise capacity. Exercise capacity tends to relate to the ability to undertake physical activity and to performance on tests of physical function, but it is a very different construct, and we know that pulmonary rehab and exercise training can very effectively change exercise capacity, and it's not so much the case for physical activity. There are many factors that influence physical activity and respiratory conditions. What we often talk about is a minimum threshold above or below which we can change activity levels. For people with a very low exercise tolerance, for example, it may be performance on a six minute walk test of 300 metres or less, exercise tolerance is associated with ability to engage in physical activity. So typically, for people whose threshold of exercise capacity is very low, our target will be changing exercise capacity so they have the ability to be active. However, for many other patients and people, above a minimum threshold, there are many other factors, and many of these are behavioural that actually influence a person's physical activity much beyond their exercise capacity. These can be motivation, habits, genetics, and self-efficacy to physical activity, and I'll talk about some of these behavioural changes and modifications shortly. And therefore, we know, as you can see from the figure on the screen, that a change in exercise capacity is not linear for most people with a change in physical activity. This is a fantastic diagram by Helene Demeyer and colleagues in their review published fairly recently looking at the end points of physical activity in chronic respiratory disease. As you can see here in the figure, they talk about physiological end points, integrated end points, and behavioural end points. And so we can consider these end points when we're considering interventions that we may target with physical activity, and particularly today, we're going to consider the behavioural end points at the far end of the figure around things that we may change, such as interpersonal environment, national and global changes. And so physical activity is dependent not only on exercise capacity, but psychological, cultural, environmental, and economic factors as well that will change how much activity someone engages in. So why is it important that we're discussing home-based physical activity? We know that pulmonary rehabilitation is effective, however we equally know, and we're well known to people in the audience here, that access, uptake, and completion rates are very poor. No matter where you are working around the world, our referral rates are low, the uptake of patients is low, and completion rates are low. So there's a very strong need to consider alternative models of pulmonary rehabilitation as well as alternative interventions to target things such as physical activity. Some of you will be familiar by the work by Anne Holland and colleagues who published this paper, the American Thoracic Society Workshop Report Defining Modern Pulmonary Rehabilitation. We talked a little bit about this in the session yesterday, but there are many new forms of pulmonary rehab that are very different to conventional pulmonary rehab. One of the things listed here on the screen is physical activity promotion in isolation. My point here is that this is not a replication of pulmonary rehab, and it can't be used to replicate pulmonary rehab. It doesn't, in its isolation, meet the definition of pulmonary rehab, but it certainly is an intervention that can be considered in conjunction with exercise training or alone for some patients, but it shouldn't be seen as to replace pulmonary rehab. Because the physical activity promotion in isolation, which I'll talk about in a bit more detail, does not typically include the exercise training and education. So moving on to measurement of physical activity before we consider interventions to target. If you're working in the clinic, there are a variety of methods that you may consider using with your patients to measure physical activity. Equally, if you're researching, there are many fantastic research-grade devices available to measure activity. We can look at our diverse number of characteristics, and some of the things here on screen talk about how to measure it. The most simplest measure is a step count, or number of steps walked per day. This works very well in clinical practice, and it's something that I use with many of my patients. They may have a pedometer or a consumer-purchased device, such as a Fitbit or Garmin. They may have a smartphone that measures their steps per day. It's a very quick and easy way to get feedback from the patient to you and from the patient to themselves. And we know that there are rough step cut-offs. For example, the table on screen shows you an example of some of those cut-offs. People walking less than 5,000 steps per day are typically considered sedentary. We also know in the COPD literature that the minimal clinically important difference of a change in steps per day is somewhere around 600 to 1,100 steps per day. So clinically, this is a great measure to use. It's typically not appropriate in research trials, because we have much more rigorous ways to measure activity. Then there are other methods. Things like the duration of physical activity and bouts of physical activity in different classes, types of activity, intensity of activity, energy expenditure, and sedentary behavior. And a wide variety of means to assess these. In the interest of time, I won't go into these in any great detail. But clinically, you may consider measures of activity, such as self-report from the patient. Maybe a standardized questionnaire that uncounts some of these categories. Or again, it may be step count, as I described. So moving on to targeting physical activity. As I described, there are really two groups of patients that I consider in chronic respiratory disease. The first group are patients with limited exercise tolerance. As mentioned, this might be people who can only walk 300 meters or less on the six-minute walk distance, just as a rough guide. Here the goal is to improve fitness levels to allow that patient to engage in physical activity. So interventions here might be optimal bronchodilator therapy, or it might be exercise training to build up their fitness level so that they do have the capacity to engage in activity. However, for many of our other patients that have sufficient exercise capacity to engage in activity, our goal instead may be behavioral strategies, if we're particularly targeting increased physical activity levels. And that's what I'm going to talk about for the rest of my presentation today. There was a fantastic review published in CHESS recently by Chris Burton and colleagues. And in this review, they looked at trials that had tried to target objectively measured physical activity levels in people with COPD. On the screen, you can see the list of interventions tested. The N represents the number of trials. And the ones in bold, the mobile health and electronic health and the activity monitor-based physical activity behavior change interventions, were really the only ones that showed promise in terms of changing physical activity behavior. You can see there's been many different interventions tested, such as exercise training alone, bronchodilator use, et cetera. But the ones with the greatest promise, which I'll go into in a little bit more detail now, are really around this behavior change type intervention. The conclusion of the review by Burton and colleagues was that few studies show an increase beyond the proposed minimally important change in 600 to 1,100 steps per day, and that enhancing physical activity in chronic respiratory disease patient populations is, in fact, very challenging. So to look at these two promising interventions in a little bit more detail now. The first one is behavioral strategies, and there's some people in the audience with a huge amount of experience and who have generated research in this area for the last few decades. This is where our greatest promise is in changing physical activity of our chronic respiratory disease populations. Some of the effective strategies that have been used include self-monitoring, so the patient self-monitoring their physical activity levels, plus realistic and collaborative goal setting, plus the provision of effective feedback from the clinician to change physical activity behavior. And in our session today, you'll hear more about health coaching and self-management strategies in this. We'll go into much more detail about this. What we know is it's much less effective to have static goals without feedback from a clinician. So it's also less effective to give a patient a garment or a pedometer and send them on their way without any real-time goal setting and real-time feedback from the clinician. So that collaborative relationship seems to be very important to changing physical activity behavior. There are other factors to consider, though, in using these interventions, such as other external barriers that patient may have and also ensuring optimal pharmacotherapy so that they can engage in activity. So in clinical practice, this might be something like giving a patient a step counter plus dynamic goal setting with you or another clinician. And then mHealth, mobile health, and eHealth interventions. So here there is the opportunity to use technology to supplement the behavior change interventions that I've just described. Here we've seen effective trials looking at telecoaching interventions using maybe real-time feedback from pedometers with software that can provide the patient and the clinician with real-time information around their activity levels. It might be with personalized goal setting and problem setting using technology, motivational messages, text messages to the patients encouraging them, giving them feedback on their activity, as well as self-monitoring of physical activity levels. But again, in the data looking at mHealth and eHealth interventions, self-monitoring alone does not appear to be effective without discussion and interpretation of the findings with a clinician or a health coach. There was a fantastic trial published or released fairly recently, the PhysatCo trial, that showed effectively they could change physical activity levels in people with COPD. When we look at the intervention delivered in this trial, this was an interaction between the patient and the clinician who acted as a health coach. Here the role was to identify the patient's needs and beliefs, enhance autonomous motivation, elicit their personal goals, formulate strategies to achieve these goals around physical activity, and evaluate and readjust these strategies. And so they did effectively change physical activity levels in this trial. And this paper goes into details of the mechanisms behind how physical activity levels were changed And they identified there were three mechanisms behind the patients with successfully increased activity levels. These were readiness to change, intrinsic motivation, and perceived confidence. So they're the types of targets that we're aiming for to try and change physical activity. So in the last couple of minutes of my presentation today, I'd like to summarize some of the things that we may consider, some of the factors relating to physical activity and chronic respiratory disease, and a variety of ways that we can change them. And this is work by Thierry Troosters and colleague, if you're interested in reading into more detail their review on this topic. Here the table shows you along the vertical axis, the variety of different factors influencing either directly or indirectly physical activity and chronic respiratory disease. If we want to target something with a behavior intervention, such as I've described today, or maybe a social intervention, we know we can effectively change awareness of behavior, self-efficacy, mood, health beliefs, motivation, social contacts, activity levels of loved ones, as well as group activities. So they're the types of things that we can effectively change that relate to physical activity. Instead, if you're looking at an exercise training program, such as pulmonary rehab, we can effectively or indirectly change things that may be related to physical activity. Here we know we can change lung function, exercise tolerance, self-efficacy, mood, and social contacts as well. So depending on the patient that you're working with, their particular impairments and particular needs, you may consider an intervention that best meets their needs. And finally, I'd like to give you a practical example of a trial that I'm leading in Melbourne, Australia at the moment. We're looking at people with lung cancer after surgery. This is a randomized control of a home-based physical activity and self-management intervention for people at 12 weeks after surgery for lung cancer. If you're interested in the trial, there's a lot more details on clinicaltrials.gov. What we're doing here is we're testing this 12-week program after surgery for lung cancer. And we have a combined behaviour change self-management intervention alongside unsupervised exercise training. So we're trying to target both aspects in this rounded intervention. Here we have behaviour change counselling with a phone call with a physiotherapist once a week. We're looking at the patient's readiness to change and their confidence, identifying barriers enables them to actively engage in exercise and their physical activity, brainstorm strategies to overcome those barriers and set goals. We're giving them an activity tracker for self-monitoring. We're giving information about the importance of activity, plus we're prescribing an exercise program for the patient to do in the home, so we're looking at a rounded program. In conclusion, physical activity is an important but challenging endpoint to targeting chronic respiratory diseases. Typically we know that exercise training alone is not enough to change physical activity for many of our patients. Practical interventions show the greatest promise, and easy-to-use practical things such as a step counter and dynamic goal-setting with the clinician may be a feasible and effective method to use clinically. But please consider other factors influencing physical activity in your patients and target these accordingly, including exercise tolerance if needed. I thank you very much for your attention. All right. Health coaching. Well, first, I have no disclosures. And this is a brief description of an overview of the relevant topics of health coaching and behavior change in COPD that expanded over the past 20 years or so since I've been working on this topic. And later in my presentation, I'm going to talk about a randomized controlled trial about health coaching to promote physical activity that was just talked about. I'm continuing to pursue approaches today at the VA to integrate health coaching and the clinical care of patients with COPD. And more recently, this work is intended to explore alternative approaches to deliver what is provided by pulmonary rehabilitation programs. Now that's meant to be provocative. It's not going to replace, but I think for many patients, it may be the only option for them to expand physical activity. So here are my objectives. My goal is to highlight the importance of providing behavioral self-management support to improve health outcomes for patients with COPD and how health coaching can help us deliver this support. Now health coaching is a patient-centered process that requires specialized training, such as motivational interviewing, and is recognized as an optimal approach for managing chronic conditions such as COPD. The process starts with identifying patient's healthcare-related values and preferences. That is, what really matters to them. If it doesn't start there, we're never going to make any progress with the patient. And they also often have many unmet needs that need to be addressed before they're going to be willing to participate in physical activity. So I think that over time, really what it takes is a health coach who can support and develop trust with a patient to make these behavior changes. So here's a definition of self-management support that a number of health services researchers developed, including several people in this room. It's an interaction with the patient to identify health beliefs and self-efficacy, elicit personalized health goals and priorities, what matters most to the patient, use shared decision-making to make and tailor appropriate strategies, and then use behavior change techniques. Let's see. So why target lifestyle behaviors? Well, we all know that lifestyle behavior, such as smoking, is critically important, and that's something we've known for a long time. But COPD causes many diverse lifestyle changes, such as sedentary behavior that was already talked about. And if we don't address this, we're never going to make progress improving health outcomes. In addition, COPD requires adopting new lifestyle self-management behaviors, including smoking cessation, but also being physically active, eating healthy, coping with chronic symptoms, and that's something I think is really underestimated. People don't understand why they're short of breath, and that's something that they continue to focus on, and want a magic bullet to try to treat that, and understanding that they're going to always have chronic shortness of breath, and we need to help support them and help them understand. Medication adherence, and then managing all the comorbidities, 30% of our patients have congestive heart failure, diabetes, they're doing, they're self-managing many different chronic illnesses, and if we just focus on COPD, it's going to be frustrating for everyone. I think that the fact of self-management was well-described and recognized by Wagner et al. back in 1996, when the chronic care model was first published. And in the, let's see if I can get the arrow, no. So in our usual interaction with patients, the doctor or health provider interacting with an informed, in the ideal situation, informed activated patient that's working in a health system that provides self-management support, but I think the reality is that that doesn't happen. I think with health care reform in the U.S., we've made improvements in information system, the electronic health record, deliver system design such as the primary, the patient-centered medical home, but I think we have a lot of opportunities for further improvement in self-management support, decision support, which are part, I mean decision support is part of self-management. So we have a lot of, I think, opportunities for improvement in those areas. Now there's lots of barriers associated with providing self-management support, and this was described in a qualitative systematic review published by Russell et al. of self-management support barriers of facilitators for self-management support. And patients report, they have limited knowledge of their COPD, and I see this all the time. They don't understand why they're short of breath, even though they've been told they have COPD. They're told they have COPD, but little other information about what it means, and they don't understand why they're short of breath. They're frustrated by conflicting information from their primary care and their specialist. They have many losses in their life. There's stigma associated with COPD. They otherwise look healthy, but they are clearly very severely limited with their shortness of breath, and they feel worthless because this is something they brought upon themselves. They have lack of trust in the health system, in their provider oftentimes, and there's a lot of fear and anxiety about what the future holds for them. On the clinician side, they're focused on exacerbation, medications, and smoking, but not physical activity or just self-management support and coping. They view self-management support as beyond their expertise, and they need to refer to other health professionals, but other than pulmonary rehabilitation, there are really no other health professionals that are providing self-management support, and there's oftentimes a communication gap between primary care and specialty care, and that leads to, contributes to the confusion. So here's a summary of a Cochrane review that was recently published about self-management interventions. This included over 6,000 participants in 27 randomized controlled clinical trials. Now the interventions in these trials was highly varied that are shown here. Some focus on exacerbation recognition and action plan. Some focus on home-based exercise or physical activity, smoking cessation or coping, and various combinations of these things, but in all of these, regardless of the intervention, the outcomes were improved in terms of health-related quality of life, lower COPD-related hospitalizations, no difference in mortality, but they were unable to reach clear conclusions about what were the specific components of the interventions were, but these results, I think, are encouraging for providing self-management support. Now one thing to note in these trials, that most of these interventions were delivered by health professionals, and I don't think this is realistic in the real world. I think, and that's where, I think, a lay health coaching is going to be so important going forward, and this is a conceptual model of health coaching for self-management support with lay health providers that was published by Tom and coworkers, and this work was conducted at the San Francisco VA with under, you know, patients with low socioeconomic status. But these health coaches, these were lay health coaches. They provided education, personal support, decision support, and they provided a bridge between the patient and clinician, which are all the components of effective self-management support. And they did these follow-up interviews with these, with the 20 patients, 11 primary care clinicians, and three specialists, and two health coaches. And the main themes from these evaluations of this self-management support delivered by these lay health coaches were that there was improved behaviors, for example, physical activity and medication adherence and COPD management. Through the longitudinal relationship and flexibility of the health coach, they developed more trust in terms of what the health care team was trying to provide, and they found that the lay health coaching was acceptable and valued by the patients, primary care specialists, and the health care specialists. And this was a summary of a lay health coaching randomized controlled trial that I conducted a number of years ago. We enrolled 325 patients with stable COPD, 156 were randomized to usual care with just COPD education, standardized COPD education, and the intervention group received physical activity coaching that was delivered by a lay health coach, and delivered only with telephone coaching. And this was before smartphones, or just as smartphones were coming out. And we relied on self-reported physical activity, since doing research-grade physical activity monitoring was way beyond the budget for this trial. So the COPD education was delivered by workbook and delivered weekly by the health coach over six weeks by telephone, and the physical activity coaching was delivered by workbook and weekly calls over five months. So you can see this is a prolonged health coaching intervention. And in this intervention, we did not find any overall difference in our primary outcomes of the CRQ dyspnea or six-minute walk. However, in subgroup analyses, the six-minute walk distance did not change over the 18-month follow-up period, whereas in the control group there was a decline. So what this tells me is that the physical activity coaching and physical activity that they participated in helped address the deconditioning that they would otherwise experience by not maintaining physical activity. And then in secondary outcomes at 18 months, we found in the self-reported physical activity that nearly 74% in the coaching group versus about 60% in the control group reported being persistently active at the 18-month follow-up period. And this was associated with a decrease in severe COPD exacerbations. So these are promising results that I think have been supported in other health coaching trials that have been done since then with more advanced technology for measuring physical activity. So I think the bottom line is I think health coaching is a feasible and acceptable way to support patients with COPD that cannot be supported by health professionals. And I think that the trained lay health coaches is to me what the future holds for promoting physical activity in patients with COPD. And while it's not a replacement for pulmonary rehabilitation, I think the reality is that the vast majority of patients in my experience would rather be doing things at home in a more real-life setting situation with daily physical activity. So thank you. The intention of meeting here was to share with you real-life experiences and work that we're doing, the know-how of things. That's why we include the essence of changing the bottom line, how much people move in their own life, how health coaching may change all that by actually having that engagement, that's talking to people, then the real-life experience, and then what happens when everything needs to be implemented. I work at the Mayo Clinic at the Mindful Breathing Laboratory. And the idea is that we try to include this mindful work means that we're trying to kind of be aware of things that happen in day-to-day and as a foundation in changing outcomes. I mean, my work is funded by the NIH, luckily, by doing, you know, many things, health coaching for COPD, after hospitalization, kind of doing mindful breathing in patients with COPD, kind of trying to study the mechanistic of health coaching, how it actually works, and then now works extending into sleep apnea, ILD, lung transplant. I don't want to repeat that again. Pulmonary rehab improve everything. Everything that you can think of is improved by the pulmonary rehab that we know, going to the center for eight to 12 weeks. But the reality is that we are just targeting this piece of the iceberg only, and we are actually not targeting the wholeness of people that are under there, under the water. So I think I want to use the words of my friend, Jim Bourbon, this morning, saying, we need convenience and flexibility. So when we actually encounter the patient, we can show what actually works from the regular rehab, but also we need to kind of bring what actually works for you. Like Dave said, what matters for you, and what can we do for that? So home rehab became a safe option that is actually growing. A lot of data is coming, not as much as the other, of course, because it's newer. And so I'd like to share briefly what I've done, the RCT that I have done, in which we randomized 375 people. We didn't really need to push these people, and we told them what to do, just because they will be randomized to kind of the intervention of home rehab with health coaching, or home rehab of 12 weeks so everybody actually get it. The outcome was here at three months. When we actually told people what to do, we're entitled, we will talk to somebody that will care about you, they will ask you about your stuff, and they will actually see your life through a monitor. Everybody wanted to do it. So we didn't really need to push anybody. We measure kind of, with an active graph, we measure, we have a careful measure of physical activity. We actually measure health-related quality of life, and then CRQ, chronic respiratory questionnaire, was our outcome. This is the system that we use. A Walmart, that you can actually buy a Samsung tablet that connected to a Garmin, and to an oximeter, and when people do their movement every day, sitting or standing, all that data went through the tablet, through Bluetooth, and then to my server, to a server in my laboratory, and everything go back to the tablet so the patient can actually see, self-monitoring, what Catherine was saying today, as one of the essence of actually behavior change, so they were able to see what they do, but also go to the health coach, and the patient and the coach talk about stuff. Stuff is this. Oh, Mr. Jones, how much did you walk on Sunday? 5,000 compared to 500. Oh, that's the day I go to Walmart. Actually, you don't have to talk with Walmart. I say Walmart many times today, but the point I want to make is that when people recognize that some activity that they love are associated with more physical activity, and that is, I mean, we didn't really need to put goals as how many steps you want to walk. No, we talk, what matters to you to do? What do you like to do? And then people say, oh, I wanted to do this, and then they work toward that, and that naturally increased physical activity in steps. Then we were able to actually see how many days, how many minutes, every day, they actually do the upper extremity and the lower extremity. We did have something that it departs from the usual pulmonary rehab in which we prescribe physical activity. We didn't prescribe exercise capacity. That's why this study will not be on the RCTs for pulmonary rehabilitation because we didn't prescribe exercise. But also we ask every day, how are you doing today, well-being? What's your breathing today? What's your energy? And what is the progress to your step goal that you actually mentioned to us? The interplay of all that, talking about that life with people will actually create a lot of engagement. We talked today about engagement with people. When we talk about things that matters to people, then engagement comes. So my job was, or my work has been inspired by many people. But the thing is that we start working on just health coaching. In this study published in the Blue Journal, we just randomized to health coaching. I mean, no technology, no nothing, you know, 10 years ago. And that study, just talking to people for 12 weeks about what they want to do, they actually decrease readmission from 10% at the Mayo Clinic to 2% at one month, and then improve quality of life in all the domains. In coaching, there's a rule. It means the R is for resisting the right reflex, resisting that I know what you need to do, and that because people are the experts, we understand why people want to change. We deeply listen, we shut up, and we actually ask what people want to say, and we empower people to do what they want to do, the vocation part. A coaching call is measured by four kind of clear stages. Number one, engage the people, have a real conversation. Focus on the one thing about why they want to change, and then we make a plan. Every time, the same thing. The four processes of motivation and interviewing. And we improve the physical CRQ by more than 0.5. This is the intervention. This is the control. This is, we improve the CRQ emotional by 0.52. Intervention, control, and the domains. The dyspnea, most important for COPD. The fatigue, second most important symptom in COPD. Emotions, 40% of COPD have depression. And mastering self-management. We also improve the MMRC, and then we improve also the daily steps. This is measured by the actigraph, by about more than 500, more than 600 steps a day. The self-management ability score improved too, and the daily physical activity, this is number of minutes of physical activity between two to four minutes measured by the actigraph, improved from 493 minutes to 516. We improve depression. More than two points, that is meaningful. And then we improve also the anxiety GAD2 score. This is just the intervention, and you can see that the improvement that we got at three month, slightly decreased after the coach finished talking to them, but didn't really go back or down to the baseline. So we promote a behavior change. We improve all domains of physical activity. We did improve physical activity and sleep. We improve self-management, and we improve depression. I wanna devote the rest of my presentation beyond the accomplishment of the research, is to how do you put it into practice, the implementation, such that we don't talk too much. We use the EPIS framework, exploration, preparation, implementation, and sustainment. Exploration means pretty much adopting the decision to actually put something in the practice. Then the preparation is may actually put all the pieces together. And then we are currently at the Mayo Clinic and the implementation phase. And then we will come into the sustainment phase after that. So we are following the implementation using a very rigid, I mean, the science-based framework. And these are all the pieces. Let me just say one thing. Implementation is such a humbling process, because in the research, the PI say, you do this, you do that, this is what we measure. When you go into implementation, you depend on a lot of people for that to happen in real life. It's really a very humbling thing. So we work on, what is the vendor? You think I choose the vendor for that? No, my institution decide that. So the relationship between the vendor and us, how we created a workflow from the doctor clicking in Epic until the situation is done, how's that gonna happen? Who's the staffing that's going to do it? So who's gonna train it? What are the billing codes that we will use? How actually we make this to work? I mean, what are the metrics? We use proctor implementation metrics, kind of adoption, adherence, penetration, sustainability, and outcomes. We need to have Epic, the people that actually do all the computation. I mean, and then, but the most important thing is that we need to have the organizational readiness. Until my boss and the Mayo Clinic decided this is going to be done, nothing started. So it's a very, kind of once you have the P values and you publish that in a good journal, then the work start to actually make it to happen in real life. So all those things actually is what we need to work with to be able to go, I'm sorry, to go from the kind of exploration, which is deciding whom we have as being the one that we want to implement, and the preparation phase. All those things need to be worked out. I mean, and then a lot of kind of meetings and decisions, and now we are rolling. The first patient is December 1st. So this is just to show you the timeline that everybody needed to actually have. I mean, the workflow that we put together. The billing code that we're planning to use, these are the RPM codes, and then the remote therapy code that probably are the ones, I mean, actually are the ones that we want to be using. So I want to just, perhaps you want a picture of that? Go ahead. All right, so the thing is that, the point I want to make is, I think that we are in the process in the pulmonary rehabilitation domain in which we need a portfolio. What actually kind of matters, and what actually apply to the patient that is in front of me. And then, once that happen, I think that we have enough evidence to kind of increase that portfolio with different things. In the VA, it could be the whole health. In the Mayo Clinic, it would be the home rehab. I mean, but the different things, and then we will learn about the passive monitoring, marrying with home rehab, that Nima's gonna talk in the next lecture. So we need a portfolio and offer that. So the iceberg, the tip of the iceberg will be smaller. We actually will see more of the number of people that we actually can tackle. So I think home rehab is ready for implementation. I think the other thing is that it will never hurt. We are not gonna do harm. In this simple, non-supervised movement of the upper extremity and lower extremity, we have 6,000 events monitored with zero side effect. It's safe. Of course, it's not pushing. We're not prescribing exercise. It's a different flavor. But we need a different flavor to have the portfolio so we can get to more people. I think that health coaching is just one of the ways to create behavior change. And that is the part that we need to kind of infuse into our rehab culture. We have the exercise culture. We just need that other piece, behavior change. And that requires training. Remote monitoring is the venue, I mean, to make it financially feasible. The rehab coach will not pay for the regular home rehab. So that's why we need to dance with that. So that's why we use RPM code, remote patient monitoring, or remote therapy codes. And I think that once we have that in COPD, we will be translating that into other things, into obesity, into diabetes, into heart failure. I mean, at the Mayo Clinic, the idea is that COPD, but ILD, bronchiectasis, pre-transplant, post-transplant is gonna be the idea because most people will be able to attend. And the other good thing is that we can involve the caregiver. I didn't say much about it, but the caregiver is somebody, very important person that we need to talk to because that is the one that will actually, will take the torch there when the coach finish. And there will be a number of things learned in that dyad, caregiver, patient, health coach, that will be maintained by the caregiver. So the home, I mean, the video visit and seeing the patient and seeing the house make a difference. And that's what I have. Thank you so very much for your attention. Thank you. I think that's a great segue into taking what you've seen and what you've learned about the motivations and the designs of these home-based pulmonary rehab interventions and deploying them in reality in private practices and in health systems and beyond. So that's what I'm gonna be talking about. And for disclosure, I'm an employee of Spire Health. You'll hear a little bit about why I'm gonna be talking about this. This is not regulatory, financial, or legal advice. And the context here is that Spire is a commercial service. The goal is to support practices and providers to improve care quality through continuous respiratory monitoring, as well as this home-based, health coaching-based pulmonary rehab intervention that Roberto spoke to. So I'm gonna make this conversation really be focused on what we've learned from providers going out and deploying this to them. So what we've learned about their needs and their reactions. So some of the things that you might be thinking about as you consider how you would deploy home-based pulmonary rehab in your practices. So beyond what my colleagues spoke to, these are the things that come to mind when we talk to them about the possibility of offering home-based pulmonary rehab. One is the accessibility. So even in practices who do have a center to do pulmonary rehab, accessibility is still an issue because coming 30 minutes, 40 minutes, even 20 minutes, as you can imagine with these patients who have complex conditions, can be a challenge. Patient engagement. A lot of times what these providers are hearing is very reactive, right? When patient's health status is declining. But this is an opportunity for them to offer something proactively and add a different kind of an intervention to their care and engage patients in a very different way with self-management and with their disease. That kind of segues into positive feedback. So as you can imagine, these patients kind of are responding and adapting to a number of different negative experiences and deteriorations that's occurring. But health coaching and pulmonary rehab offers the possibility for, in their words, tiny wins and a very explicit, different kind of value proposition that a provider can offer to their patient. And then finally is the evidence-based. So in our company, we offer continuous respiratory monitoring as a means of predicting exacerbations and anticipating them and intervening earlier. There's not a lot of literature around that. We're providing a lot of it, but it's emerging. That's in contrast to the pulmonary rehab and virtual pulmonary rehab evidence-based. That's crucial not just for providers to base their decisions upon, but also to get buy-in from their own peers because a lot of these practices are making decisions in consensus or they're influenced by their peers. So this evidence-based is quite important. But let's talk about reimbursement. That's, of course, top of mind for any practice. This is cut and paste directly from the CMS website. I'm not going to go through it in detail. I imagine a lot of you have seen this. First is the definition of how CMS frames remote physiologic monitoring. You can see some of the requirements there, right? An established relationship, patient consent, eligible practitioners. Those are all kind of gimmies. And there's some guidelines there as well. The data needs to be captured automatically. It's physiological data that's uploaded and available to the billing practitioner. The device should be a medical device. Data capture for at least 16 of 30 days. That seems like quite a modest requirement. But what I encourage the providers to do is to think past one, two, even three months. Think about years. How are you going to continuously provide monitoring, provide the possibility of pulmonary rehab when necessary, and continue to make it financially sustainable as well? So 16 days seems low, but we'll come back to how we can make sure that it's easily attained. It can be an acute or chronic condition. And of course, the personnel that provide these services must be done under the supervision of the practitioner. Now, what codes in particular in the US do we use to do this? And these are the remote physiologic monitoring codes. And here's how we use them. The first is a consent code that's billed. And I think what's important to know about this, this is a one-time code that's used. But it can be done by a third party. In our case, we do this on behalf of providers, which is just another thing that allows the providers to make this kind of a turnkey experience as much as possible. And then on a monthly basis, there's really two categories of codes. One is the 99454, which is the data capture, which I spoke to is about at least 16 days out of 30. And then there's the care management codes. And that's where the clinician is interacting with the patient or reviewing the data that's captured by the system. So the data capture code, as I mentioned, needs to be low burden. But the care management can also be remote. And the way it works is that there's a kind of base 99457 code that's used. And then one or two or zero of the 99458 codes would be billed. And that's relevant because in a pulmonary rehab or remote pulmonary rehab context, those codes are very useful because there's more time spent with patients, more time reviewing data, more coaching that's done. And that's how it's done. So let me take you through an example. Normally, you think about an example, you're going to think about a 12-week virtual pulmonary rehab process. But I encourage the practices and providers to think longer term. Think about a year, not just for your business or your practice, but also for your patients. These are chronic conditions, and you don't want to be just thinking about them in a 12-week intervention. Let's go through the first three months. So the way that SPIRE does this service is that we are always offering this acute exacerbation monitoring. That's kind of baseline. That's always happening in the background. And then on top of that, we may or may not layer in the pulmonary rehab intervention according to the provider's referral and the patient's consent. But in this instance, the patient has consented. So you can see the 99454 code is used. That's a one-time code. And then for each of the months in that period, there's the data capture code. That's the 99454. And then a care management code. And then you can see I use 1.5 as the number of codes for 99458 that are used. Because that varies according month to month or according to the patient's needs. Now, when that 12-week period is over, you want to be asking yourself, now what? And that's where one of the things we've been trying to solve is the question of maintenance. That's one. And the other is around re-engagement with VPR. I think that there's starting to be some evidence around patients doing VPR multiple times, even within the same year. I think we're going to start seeing that more and more just because of the patient's responses to this kind of intervention, where it's so accessible. They're getting health coaching, something that they don't normally get. And they're able to be passively engaged. And that's a phrase that we use at our company, where it reflects the patient's natural inclination to engage in an intervention. I want to be passive when I want to be passive, and I want to be active when I want to be active. And I want you, as a service, to allow for me to do that and have it be OK. So in the months 4 to 10, there's a maintenance period. Acute exacerbation monitoring is still occurring. And the 99458 codes drop, because there isn't as much health coaching that's occurring during this maintenance phase. And then potentially, the patient may decide to re-engage, or the provider may determine, well, we've got now your VPR data during the first three months, and then it seems like your physical activity is dropping over the past six, seven months. Now might be a good time to re-engage. And so if we didn't have that data, then we wouldn't be able to have that in conversation and engage patients to be motivated to do it again. And of course, with the way that we deliver health coaching, it's really taking Roberto's intervention. It's very patient-centered. So patients' needs evolve over time. And that will also allow patients to engage. Maybe it's every year. Maybe it's every other year. Or who knows, according to their needs, the topics of that engagement may also evolve over time. So that's a little bit about how at least our company deploys the service. And I think what's key there is this idea of these natural complements, where right now we're seeing these things in isolation. And the evidence around acute exacerbation, detection, and anticipation is quite emerging. But in the future, these are really two sides of the same coin if you think about COPD patients and their needs over months and years. One side is going to be that acute exacerbation monitoring. And that's where the company started. Now those exacerbations may be nine months apart, 12 months apart, six months apart. There is periods of time where you need to sustain the patient's motivation to keep wearing the sensors, to keep checking in with a clinician, to stay engaged and involved just enough in case for that exacerbation to occur six months from now. So that's one problem. The other is the benefits of pulmonary rehab, which have been discussed already. So our company want to do everything possible to prevent these admissions. And that's really core. So just to explain this and to visualize it, the device that we use is called the health tag. And that's a continuous respiratory monitor. It goes on their adhesives that go on the inside of the undergarments. So that's our solution to creating a monitoring platform that's truly passive. And that's this passive engagement that I was speaking to. The data is captured, and then our clinicians can talk to patients about, hey, Ms. Johnson, we've noticed your breathing has changed over the past 24 hours. How are you feeling? Are there new symptoms and so on? And we can conduct a risk assessment. And then if that fails, a patient gets escalated to their provider. That's all well and good. And the provider can determine whether or not they intervene. That's all well and good. But what we found is that even with this highly passive sensing capability, which is just wear your underwear and the data is tracked, there's no charging or anything, there is another feedback loop where on all those months and all those weeks where there is no physiologic deterioration, there is no strong change in symptoms or symptom onset, the patient can be engaged in different ways, A, for self-management purposes, and also to prepare them for when that deterioration may or may not come three months from now. And so that's been a really nice way for us to layer this in. And now when we go to providers, and we've been deploying this service to private practices and health systems for a few years now, but now when we're going to these practices, we have a very different conversation with them because the providers really see both sides of the coin. And even if they are interested in this kind of long-term monitoring for acute exacerbations, they're quite receptive and excited to be able to finally offer a home-based pulmonary rehab in a way that has a long-term implication. So there is something after that 12 weeks because providers are quite busy, as you know. That's, in a nutshell, how our company thinks about this and how it complements the acute exacerbation monitoring and the needs that these providers are seeing from, that they're expressing from the field. So thanks for your attention today. Happy to talk about any of your questions. Thank you.

home-based pulmonary rehabilitation

chronic respiratory diseases

traditional programs

low participation rates

health coaching

personalized support

barriers to participation

remote physiologic monitoring

reimbursement codes