Please select the eligibility criteria that correspond to the clinical trial below.
Title: An Integrative Multilevel Study for Improving Patient-Centered Care Delivery Among Patients With Chronic Obstructive Pulmonary Disease
Brief Summary: This study involves development and testing of a patient and family-centered transitional care program for patients who are hospitalized with Chronic Obstructive Pulmonary Disease (COPD) exacerbations. The study intervention includes tailored services to address individual patients' biopsychosocial needs, starting early during hospital stay and continuing for 3 months post hospital discharge.

The study hypothesis is that compared to usual care, the study intervention will : a) Improve patient health- related quality of life and survival, and reduce use of hospital and emergency room visits; b) result in improved patient experience, self- confidence, and self-care behaviors; c) result in improved family caregivers coping skills, self-confidence, and problem solving skills to address patient barriers to care and treatment.


Options:
A: Inclusion Criteria:

* Clinical diagnosis of chronic lower respiratory diseases (ICD10: J40-J47) recorded in electronic medical records since January 1st 2010

Exclusion Criteria:

* No exclusion criteria
B: Inclusion Criteria:

* Patients will be 55 years old and above
* A history of hospital admissions for COPD related issues
* Able to designate a support person that can help them manage their condition
* Discharged home

Exclusion Criteria:

* Dyads unable to participate in the education session
* Patients discharged to a skilled nursing facility or rehabilitation facility.
C: Inclusion criteria:

* Admitted to the hospital with a diagnosis of an acute COPD exacerbation; OR has a previous COPD diagnosis\* AND receiving treatment to control COPD symptoms - (e.g. nebulizer treatment, prednisone course, ...) in the current hospitalization
* Age \> 40 and \>10 pack-yrs smoking
* English speaking
* Anticipated discharge back to home (rather than to Hospice or long term nursing home placement)

Exclusion criteria:

* Severe cognitive dysfunction
* Terminal illness (less than 6 months life expectancy) that is non-COPD related
* Homeless (no home address)
D: Inclusion Criteria:

* Over 18 years of age
* At least one target chronic medical condition:
* arthritis
* asthma
* chronic obstructive lung disease
* diabetes
* heart failure
* or hypertension.
* Evidence of a behavioral problem or need:
* Diagnosis of:
* anxiety
* chronic pain including headache
* depression
* fibromyalgia
* insomnia
* irritable bowel syndrome
* problem drinking
* substance use disorder
* OR persistent use of certain medications used for behavioral concerns:
* antidepressants
* anxiolytics
* opioids
* antineuropathy agents
* OR persistent failure to attain physiologic control of a medical problem:
* blood pressure\>165 while on 3 or more medications
* A1C \> 9% for 6 months)
* OR the presence of three or more of the target chronic medical conditions.

Exclusion Criteria:

* Not seeking care at a participating practice
* Inability to consent due to cognitive and/or developmental impairment/delays
* Living in the same household as a previously enrolled study participant

Answer: C