DESCRIPTION (provided by applicant): Chronic obstructive pulmonary disease (COPD) exacerbations are common among Veterans admitted to hospital, lead to decrements in health-related quality of life, and are important drivers of health care expenditures. COPD exacerbation rivals chronic heart failure as the second leading cause of medical service discharges within VA. The readmission rate after exacerbations is high with as many as half of patients requiring readmission within 6 months. In contrast to initiatives targeting readmission for chronic heart failure, similar efforts do not exit for COPD. Our research suggests that VA potentially misses opportunities to augment care in response to COPD exacerbations despite a number of recent studies that demonstrate successful interventions to decrease future exacerbation risk. 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, such as specialties treating patients within Patient Aligned Care Teams (PACT). The current system reflects a process that is based on a fee-for-service model where specialists wait for patient referrals and do not assume responsibility for the health of a population of patients. Specialists are also geographically concentrated at major medical centers that are culturally and physically separated from the patient's medical home. Determining how to deploy existing specialties using a PACT-Veteran-centric approach is important to improve access, timeliness, and quality of care. We propose to test a novel intervention that is aligned with VA operational goals, and seeks to improve the quality of care among patients with COPD, improve their quality of life, and reduce their hospital re-admissions and mortality. Our specific aims include: Among patients who were discharged from hospital with an exacerbation of COPD: 1. Evaluate a multifaceted intervention that seeks to improve quality-of-life and decrease rate of hospital readmission and mortality among patients with COPD. The intervention leverages the VA's integrated healthcare and informatics system to facilitate the transition from hospital to home by using a multidisciplinary team to longitudinally support discharge and primary care teams in the care of patients recently discharged with a COPD exacerbation. The intervention is also designed to provide evidence about how VA may expand the responsibilities of specialists to better support patients during high risk periods. We hypothesize that the intervention will: 1a. Improve patient quality of life; 1b. Decrease hospital admission and mortality after hospital admission for COPD exacerbation. Secondary Aims 1. Assess whether the intervention improves COPD specific processes of care; 2. Assess whether the intervention improves Veterans' satisfaction with care; 3. Assess acceptability and satisfaction of the intervention to primary care clinicians.