Chapter 8 148 means that the patients, who currently receive clinical supervision once a week, will receive clinical supervision every other week and be instructed to complete an unsupervised exercise program in the remaining weeks. During the supervised treatments physiotherapists will be asked to pay attention to self-management, including discussion of the impact of COPD and lung attacks on physical functioning. Further, they are instructed to provide education on the patient's own role in treatment and coping strategies for managing their condition according to the guideline recommendations [11]. Based on shared decision-making, the physiotherapist and patient agree on a desired form of unsupervised exercise (appropriate to the context of the patient). If the physiotherapy practice has the facility, the patient may choose to exercise independently at the physiotherapy practice. The patient may also choose to exercise independently at home or use regular sports and exercise services. For 12 months, the physiotherapist will monitor the patient's primary COPD-related health outcomes and patient’s adherence. Follow-up moments will occur every three months (consistent with the KNGF guideline COPD [11]). These follow-up moments are important in order to adjust the intensity of clinical supervision if necessary; patients should not have any decline in health-related outcome measures (including adherence). If at any follow-up moment there is a decline in any of the health-related outcome measures, the patient will receive full clinical supervision again (Figure 2). It is expected that patients who are adherent at a follow-up (RAdMAT-NL score ³ 54), are capable of more self-management while maintaining stable health outcomes over the next three months. Patients who are non-adherent (RAdMAT-NL score < 54) are expected to have more difficulty with self-management and experience a decline in health outcomes. Given this expectation, patients who show a decline in adherence scores will also receive full clinical supervision to prevent their health outcomes from declining. Figure 2 Process of supervision over time At T0, all patients start with reduced clinical supervision (partly self-management of rehabilitation). At each measurement moment (T1-T3), a decision is made whether the patient can remain in reduced clinical supervision, or move to full clinical supervision.
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