An Intervention Study of an Extended Discharge Planning and Disease Management Program on Patients With COPD

The purpose of this 4-year study is to investigate the relationship between cognition and learning ability on patients with COPD during hospitalization to establish and evaluate the effects of the community-extended discharge planning program. The transition theory is used as the theoretical base in this study. The patients with diagnosis of COPD in hospital will be invited to participate. The data of demographic variables, the cognitive function¸ the respiratory function, the effect of learning and the usage of medical resources after discharged will be collected. In the first year, we will establish the protocol of respiratory teaching in two modes, and to compare the differences among computer interaction game intervention, face to face teaching and routine nursing intervention, also to evaluate the related factors and the effect of learning on patients with COPD for determining the needs of patients' learning mode and the optimal frequency of nursing teaching mode during hospitalization in the second year. For the second year, build upon the results of the first year, the preliminary draft of the community-extended discharge planning program that base on the experts' meeting and the interview with the patients. Also, a pilot study that revising the content and testing the feasibility of respiratory teaching protocol will be conducted. For the 3rd and 4th year, using case-control RCT design, the community-extended discharge planning program will be tested in patients during their hospital stay and post-discharge period. The effects of this community-extended discharge planning program will be evaluated on outcome variables of patients' cognitive learning function, utilization of health care resources. The results of this study will help to develop a community-extended discharge planning for patients with COPD on cognition level and learning ability. Furthermore, the protocol of the community-extended discharge planning will serve as references to prolong the development of disease deterioration, reduce the probability of readmission and improve the quality of life.