[Impact of an Integrated Care Model in Patients with COPD and High Risk of Readmission].

Chronic obstructive pulmonary disease (COPD) is associated with high morbidity and healthcare utilization, particularly due to acute exacerbations leading to Emergency Department (ED) visits and hospital admissions. Patients with multimorbidity and social vulnerability are at increased risk of readmission. The aim of this study was to evaluate the impact of an early, multidisciplinary, integrated care model on ED visits and hospitalizations among high-risk patients with COPD. A single-center pre-post intervention study was conducted following implementation of the Early Pulmonology Assessment/Individualised and Integrated Care Plan (EPA/IICP) protocol in February 2024. High-risk patients were identified using the LACE Index (> 9, or 5 - 9 with additional risk factors). The intervention combined medical, nursing, and social assessment with hybrid follow-up (face-to-face and remote monitoring). The primary outcomes were the number of ED visits and hospitalizations in the year before and after enrolment. Paired Student's t-tests were used for analysis. Fifty-three patients were included (mean age 67.6 years; 62% male). Baseline comorbidity and readmission risk were high (mean Charlson index 4.5; mean LACE 13.8). After one year, mean ED visits decreased from 3.09 to 0.67 (p < 0.001), and hospitalizations from 1.39 to 0.33 (p < 0.001). Remote monitoring generated early clinical interventions, with only two admissions for severe respiratory failure. Social intervention enabled most patients to maintain or regain home-based care. An early, integrated, hybrid care model was associated with significant reductions in ED visits and hospitalizations in high-risk COPD patients. This approach may represent a sustainable strategy for managing complex chronic respiratory disease.