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

Inclusion Criteria

• •COPD defined as chronic irreversible airflow limitation with FEV1 \< lower limit of normal for age as % predicted and a FEV1/FVC ratio \< than lower limit of normal (usually 70%) \[5\]
• •Plus ≥ 2 comorbidities commonly associated with COPD as identified in the Canadian Thoracic Society COPD guidelines\*
• •1. Cardiovascular disease
• •2. Osteopenia and osteoporosis
• •3. Glaucoma and cataracts
• •4. Cachexia and malnutrition
• •5. Peripheral muscle dysfunction
• •6. Lung cancer
• •7. Metabolic syndrome (diabetes mellitus)
• •8. Depression
• •9. Chronic kidney disease OR Other conditions as primary admitting/presenting diagnosis + COPD as significant comorbidity + ≥ 1 other comorbidity
• •THAT
• •1. Get admitted to participating hospital; or
• •2. Present to participating hospital ED; or
• •3. Have first referral to Respiratory Centre/Respirology team
• •AND HAVE
• •1. ≥ 1 ED presentation/hospital admission in previous 12 months
• •2. ≥ 50 years age