Integrating Care After Exacerbation of COPD

Chronic obstructive pulmonary disease (COPD) exacerbations are common among Veterans admitted
to hospital, lead to worsening health-related quality of life, and are important drivers of
health care expenditures. As many as half of patients discharged for COPD are readmitted
within 6 months. An intervention to improve COPD care is needed, not only to treat patients
for COPD and their accompanying comorbidities, but also to redesign the care delivery system.
The goal of this clinical trial is to test an intervention to improve patient care during the
transition from hospital to outpatient setting for patients discharged for COPD. The
investigators are targeting the intervention to Patient Aligned Care Team (PACT) providers
who are randomized to receive the intervention or not receive the intervention. For the
intervention, study clinicians, consisting of experienced primary care providers and
pulmonary specialists, reviewed the medical record for each patient discharged from hospital
for COPD. The team looked for gaps in care for COPD and key co-morbidities such as obesity,
hypertension, diabetes, and cardiovascular disease. They focused on immediate care processes
associated with the hospital admission and comorbid disease treatment. For providers in the
intervention group, the team placed any patient care recommendations into the medical record
using a non-visit consult note and pre-filled order sets. The patient's provider then
accepted, modified, or declined any or all of the recommendations based on personal knowledge
of the patient's history. The investigators hypothesize that the intervention will: 1)
improve patient quality of life; and 2) decrease hospital readmission and mortality after
hospital admission for COPD exacerbation.

Inclusion Criteria:

Providers:

- Primary care provider (MD, NP, PA) from VA Puget Sound or Boise VA.

- Willingness to participate in the informed consent process and complete interviews and
questionnaires.

Patients:

- Having a provider that is participating in this clinical trial.

- Discharged alive with either a primary discharge diagnosis of COPD or acute
respiratory failure with a secondary diagnosis of COPD.

- Willing and able to participate in the informed consent process and complete
interviews and questionnaires.

Exclusion Criteria:

Providers: none

Patients:

- Having previously participated in the study.

- Significant cognitive dysfunction, language barrier, or severe psychiatric disorder
that would preclude completing the questionnaires.