Program of Integrated Care for Patients With Chronic Obstructive Pulmonary Disease and Multiple Comorbidities

Conditions

• Chronic Obstructive Pulmonary Disease
• Multiple Comorbidity

Interventions

• BEHAVIORAL: 40 minute standardized education session
• BEHAVIORAL: Individualized action plan
• BEHAVIORAL: Individualized care plan
• BEHAVIORAL: Standardized reinforcement/motivational interviewing and action plan teach-back sessions
• BEHAVIORAL: Tele-home monitoring
• BEHAVIORAL: Coordinated and improved communication
• BEHAVIORAL: Priority access
• BEHAVIORAL: Dictated patient summary
• BEHAVIORAL: in-hospital rehabilitation/self-management program
• BEHAVIORAL: Smoking cessation
• BEHAVIORAL: Action plan Respirologist
• BEHAVIORAL: Web based self management materials

Sponsor

Michael Garron Hospital

Collaborators

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