Chronic Obstructive Pulmonary Disease Rehabilitation Class

Community Rehab COPD

Background information

Evidence for pulmonary rehabilitation

 Eligibility for the proposed pulmonary rehabilitation program shall be in line the NICE COPD guideline (2010). This states that “pulmonary rehabilitation should be offered to all patients who feel functionally disabled by COPD” (NICE 2010).Eligibility for the proposed pulmonary rehabilitation program shall be in line the NICE COPD guideline (2010). This states that “pulmonary rehabilitation should be offered to all patients who feel functionally disabled by COPD” (NICE 2010).Eligibility for the proposed pulmonary rehabilitation program shall be in line the NICE COPD guideline (2010). This states that “pulmonary rehabilitation should be offered to all patients who feel functionally disabled by COPD” (NICE 2010). Eligibility for the proposed pulmonary rehabilitation program shall be in line the NICE COPD guideline (2010). This states that “pulmonary rehabilitation should be offered to all patients who feel functionally disabled by COPD” (NICE 2010).

“The opportunity for structured, on going exercise with peer and professional support, in a suitable venue, is perceived as important to people with COPD in facilitating a physically active lifestyle following pulmonary rehabilitation” (Hogg et al. 2012)

According to General Practice Airways group's sharing of best practice meeting (2005) and the American Thoracic Society/European Respiratory Society Statement on Pulmonary Rehabilitation (2006), at least one supervised session is required per week for effective pulmonary rehabilitation. It has also been suggested that two supervised sessions per week may have a better impact on health-related quality of life (Liddell and Webber 2010). Making it a regular weekly program would give the program a structure and would ensure that the participants have regular support which has been found to be important in exercise regimes, especially in this population (O'Shea et al. 2007).

Therefore, to make this program as cost effective as possible, we suggest that it will contain a twice weekly exercise class as a number of individual supervisions would be capital and labour intensive.

<Program duration>

As is desirable, exercise sessions would be delivered by healthcare professionals, specifically a physiotherapist and physiotherapy technical instructor, both with experience in cardio-respiratory rehabilitation (Backley et al. 2005). The location of these sessions would be in the community as according to the COPD guidelines published by NICE, pulmonary rehabilitation classes should be held in locations which are easily accessed by participants to ensure their effectiveness (NHS, National Institute for Health and Clinical Excellence 2010). In addition, it has also been found that travel difficulties is a barrier to completion of pulmonary rehabilitation (Keating et al. 2011). The NICE guideline also says that these are to be held at times which suit the participants (NHS, National Institute for Health and Clinical Excellence 2010). These group sessions would be interspersed with exercise sessions which participants would do in their own time at home or in a local leisure facility. It is suggested that a minimum of four home sessions are completed per week (Backley et al. 2005).

As recommended by the American Thoracic Society/European Respiratory Society Statement on Pulmonary Rehabilitation (2006), a minimum of twenty exercise sessions would be included in this pulmonary rehabilitation program at a frequency of at least three per week, with one or two of these being supervised. Although any intensity of exercise has been shown to be beneficial, high intensity exercises would be encouraged for greater physiological effects (Nici et al. 2006). In addition to the traditional lower limb training included in pulmonary rehabilitation, such as treadmill walking or cycling, upper limb exercises, such as arm ergometer or hand weights, will be included as a number of beneficial effects have been noted. Ideally, aerobic exercise would be at an intensity of between four and six on Borg dyspnoea scale of more than 60% of max workload for at least 30 minutes. For resistance exercise, exercise intensity would be between two and four sets of six to twelve repetitions at an intensity of 50-80% of 1RM (Nici et al. 2006).

In addition to the structured exercise class, an essential educational component will be included in the pulmonary rehabilitation program (Backley et al. 2005). This would include teaching participants the importance of exercise. This is of specific importance with people in this population as many individuals with COPD elect not to take up a referral to pulmonary rehabilitation as they think they would not experience any health benefits from attendance. Ensuring good attendance at pulmonary rehabilitation requires consideration of how information regarding the proven benefits of pulmonary rehabilitation can be conveyed to participants (Keating et al. 2011). It is also important to supply the participants with information on how to transfer exercise into environments outside the class, such as their home, as this will be required for between supervised sessions and once they have completed the program (Nici et al. 2006).  Information on relaxation, anxiety management, medication and self management (Backley et al. 2005), including an action plan for exacerbations (Nici et al. 2006), would also be included as this seen as being essential in an effective pulmonary rehabilitation program.

Contextual issues

Patients' Experience of Pulmonary Rehabilitaion Classes

Patient A’s Story

Back before I started at breath smart I couldn’t do a lot. I was heavily dependent on oxygen and practically house bound. I couldn’t use the stairs or do my gardening or go to the shops. I was actually wheeled into my 1st class at breath smart because I couldn’t walk far at all. I must have been in hospital 8 or 9 times the year before I started these classes. I’ve been coming twice a week for just over a year and now I don’t use any oxygen at all and I will gladly take the stairs without and trouble. I haven’t been admitted to hospital once this year. I can now use the treadmill for 25mins at a time at a speed of 5.5km/hr and an incline of 3.5. I never thought this would be possible. Breath smart has given me back my freedom I can’t begin to explain the changes it has made to my life. I am however still smoking. If I was able to improve this much while still smoking I can only imagine how much better I would be if I could give them up but I haven’t been able to as of yet.

Patient B’s Story 
Before starting breath smart I spent a lot of time in hospital, my breathing was very bad and my general health was very bad also. I used an awful lot of oxygen. Confidence was a big problem. It was hard to know what to do, that was very very difficult. I had been very very active all my life and then everything came to a standstill. My consultant suggested I come to breath smart. I’m here 2 years now, and the difference in my life is huge! I couldn’t even start to tell people how much of a difference it has made to my life, but I do tell people. My family have all seen the difference it has made to my life. I’m more active. Coming to breath smart gives you an incentive, it gives you the confidence, the people here are professional you trust them, I trust everyone here they are very very good, they explain to you and tell you if you are doing too much or doing too little. This is the 1st year that I haven’t been in hospital since I was diagnosed.

Financing

Fixed Expenses:
Below is a table indicating the fixed costs of the “insert name” class by year and by month.

Table 1: Fixed Expenses

Expenses	Yearly	Monthly
Venue	3600	300
Staff (Band 5 Physiotherapist)	2027.52	168.96
Staff (Physiotherapist Assistant)	1110.24	92.52
Personal Indemnity Insurance	Covered by CSP Membership	Covered by CSP Membership
Total	£6737.76	£561.48

To calculate the staffing costs we used the following stepped equation:
1. Number of workable hours per year
• Number of weeks per year X hours worked per week
• 52 X 37.5= 1950

2. Number of hours worked per year
• Number of workable hours per year– (Holiday + bank holiday hours)
• 1950 – [(27 X 7.5) + (8 X 7.5)]
• 1950 – (203 + 60)
• 1950 – 263
• 1687

3. Cost per hour for staff
• (Salary + Employers Contribution to National Insurance [13.08% for 2012-2013]) ÷ Hours worked per year
• Physiotherapist = 21,000 + 2750= 22750, 22750 ÷ 1687 = 14.08.
• Physiotherapist Assistant= 11500 + 1504.2 = 13004.2, 13004.2 ÷ 1687 = 7.71

4. Monthly Cost
• Cost per hour X hours per week X hours per month
• 2 class per week @ 1hr each plus 15mins pre and post = 3hrs per week

5. Yearly Cost
• monthly cost X 12

Variable Expenses:
Below is a table indicating the variable costs of the “insert name” class by year and by month.

Table 2: Variable Expenses

Expenses	Once off	Yearly	Monthly</u
Stationary
Printer	49.99	16.66	1.39
Tea and Coffee		96 8
Paper Cups		48	4
Plastic Spoons		24	2
Milk		96	8
Total	£49.99	£340.68	£28.39

 The cost of the printer was worked out as follows:
1. Yearly cost
• Cost of printer (priced at PC World) ÷ 3 (estimated minimal life expectancy)

2. Monthly cost
• Yearly cost ÷ months per year

<u>Capital Expenses:
Below is a table indicating the capital costs of the “insert name” class by year and by month.

Table 3: Capital Expenses

Expenses	Once Off	Yearly	Monthly
Blood Pressure Monitor X 4	160	53.33	4.44
Pulse Oximeter	198	66	5.50
Total	£358	£119.33	£9.94

The cost of all capital equipment was worked out as follows:
1. Three quotes were explored and the average cost was taken

2. Yearly Cost
• Cost of item ÷ 3 (estimated minimal life expectancy)

3. Monthly cost
• Yearly cost ÷ months per year

Overhead Cost:
Fixed Expenses + Variable Expenses
Yearly overheads = £7078.44
Monthly overheads = £589.87

Starting Up Costs:
Capital expenses + 1st 3 month’s overheads
358 + (589.87 X 3)
358 + 1769.61
£2127.61

Cost of Service per participant:
(Overhead costs + Capital expenses) ÷ Number of participants

Yearly
(7078.44 + 119.33) ÷ 16
£449.86 per participant per year

Monthly
(589.87 + 9.94) ÷ 16
£37,49 per participant per year

Appendices

File:Exercsie class sheets.pdf