Project Overview

Chronic obstructive pulmonary disease (COPD) is a prevalent and disabling chronic condition that contributes to frailty, morbidity, and mortality in older adults and incurs a high cost to the healthcare system. People with COPD often lack the support needed to manage their condition at home and in the community, and as a result rarely seek care for exacerbations until hospitalization is needed. Many patients are readmitted to hospital within 30 days of discharge. Our collaboration to create a scalable Program of Care (CHARM-COPD) for people with COPD combines new initiatives at Toronto Grace Health Centre, University Health Network, and the University of Toronto. We will create and evaluate a comprehensive program that is feasible and acceptable to COPD patients. CHARM-COPD consists of Virtual Pulmonary Rehabilitation with a respirologist, Remote Clinical Monitoring, Integrated Care with close monitoring by nurses and therapists, and novel remote monitoring including continuous monitoring of activity, coughing and sleep. Our project aims to meet the needs of most COPD patients, including those impacted by frailty, low digital health literacy, lack of English language proficiency, and other issues that impact equitable access to care.