COPD often leads to many hospital trips, especially when patients have other health problems and face social difficulties. These individuals are more likely to end up in the emergency room or be readmitted soon after discharge. Researchers wanted to see if a new, coordinated care plan could lower those numbers for the most vulnerable patients.
The program began in February 2024 and used the LACE index to flag high‑risk patients. Those with a score above nine, or a score between five and nine plus extra risk factors, were invited to join. The team included doctors, nurses, and social workers who performed thorough assessments. Follow‑up care mixed face‑to‑face visits with remote monitoring devices, allowing early detection of worsening symptoms.
Fifty‑three patients took part, with an ave