The aim of this study was to pilot the implementation of care coordination plus early rehabilitation in a high-risk COPD population in transition from hospital to primary care.

Study Hypotheses

(1) Implementation of the pilot intervention (care coordination plus early rehabilitation) is feasible, satisfactory to patients and carers and can be delivered with fidelity.

(2) Care coordination plus early rehabilitation will result in (i) documentation of agreed patient goals and (ii) demonstrated progress toward them assessed by the four major Flinders Program™ (FP™) care planning tools: Partners in Health / Cue and Response / Problems and Goals assessment and Self-Management Plan²⁰ in at least 85% of cases.

(3) Care coordination plus early rehabilitation will involve collaboration with the patient's GP/practice nurse with generation of a General Practice Management Plan (GPMP) or Team Care Arrangement (TCA) in at least 85% of cases.

(4) People with COPD who participate in care coordination plus early rehabilitation will have lower hospital readmission rates at 28 days and greater physical activity levels at 28 days after discharge than a control group of similar patients.