Pulmonary rehabilitation and integrated care

Pulmonary rehabilitation is a multidisciplinary approach that aims to stabilize or reverse both the physio- and the psychopathology of pulmonary diseases and attempts to return the patient to the highest possible capacity allowed by the pulmonary handicap and overall life situation. Three important features of pulmonary rehabilitation include: individualization, multidisciplinarity, and attention to the different components of the disease and their impact on daily life. Current health care systems are still organized based on the acute care paradigm, largely neglecting the management over periods of years or decades, required for optimal approach of patients with chronic conditions. These chronic conditions need to be considered as the result of complex, dynamic, and unique interactions between different components of the overall system. Optimally, pulmonary rehabilitation aims to achieve optimal daily functioning and health status for the individual patient and to achieve and maintain the individual's independence and functioning in the community. As part of the integrated care process, pulmonary rehabilitation is the patient-centered demand-driven process in the care delivery value chain by offering a flexible, creative, holistic, and integrated intervention, based on partnering of different skills to achieve shared individualized patient-related objectives, as well as to achieve improvement in clinically relevant outcomes and to offer added value to the patient and the community.