Skip to main content Back to Top

University of Wisconsin-Madison

Implementation of a COPD Transitions of Care Service Integrating Clinical Pharmacists as Prescribers Within the Patient Centered Medical Home

Edward C. Portillo1,2, Pharm.D.; Molly R. Lehmann2, Pharm.D., BCACP; Jordyn T. Kettner1,2, Pharmacy Intern; Sonia D. Bhardwaj1,2, Pharmacy Intern; David E. Goodrich6, Ed.D., M.A., M.S.; Nicholas W. Bowersox6, Ph.D.; M. Shawn McFarland4, Pharm.D., FCCP, BCACP; Blake Henderson5, B.A., Timothy L. Hagen3, M.B.A.; Michelle A. Chui1, Pharm.D., Ph.D.

  1. University of Wisconsin-Madison School of Pharmacy
  2. William S. Middleton Veterans Affairs Hospital
  3. Veteran Affairs Healthcare System of the Ozarks
  4. Department of Veterans Affairs Clinical Pharmacy Practice Office
  5. Department of Veterans Affairs Diffusion of Excellence
  6. Department of Veterans Affairs Center for Evaluation and Implementation Resources (CEIR)
  7. University of Wisconsin-Madison Institute for Clinical and Translational Research

COPD is the third leading cause of death globally and will soon be the leading cause of death worldwide.1 In the United States, COPD mortality is increasing, with the COPD mortality rate doubling in the last 50 years.2 Although not fully reversible, COPD is treatable using evidence-based approaches to COPD management.3 However, to date, no single intervention has reliably reduced COPD readmissions nationally across healthcare settings, prompting the exploration of innovative approaches to COPD management.

Chronic Obstructive Pulmonary Disease Coordinated Access to Reduce Exacerbations (COPD CARE) is an interprofessional, team-based program that integrates pharmacists within the Department of Veterans Affairs (VA) Patient Centered Medical Home (PCMH) to improve the management of COPD during care transitions. The goals of COPD CARE are to (1) reduce hospital and Emergency Department readmissions, (2) improve time to follow-up in-clinic post-COPD exacerbation, and (3) incorporate evidence-based best practices within primary care delivery. The COPD CARE service incorporates best practices detailed in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2021 guideline into primary care delivery.4 Pharmacists completing service clinic visits manage patients’ COPD and associated co-morbidities with an independent scope of practice to prescribe medications, order necessary lab values, place referrals, and coordinated patient follow-up. Pharmacists focus on four priorities: (1) inhaler technique and adherence (2) assessment, prescribing, and optimization of pharmacotherapy (3) referrals for needed care and (4) development of a written COPD action plan to provide to patients.

COPD CARE was developed and piloted at one VA clinic in 2016 and has since been scaled across the United States utilizing a national training program delivered to pharmacists, nurses, and other members of the interprofessional primary care team. At the initial pilot site, 19 patients were managed through the COPD CARE service over a six-month period. No hospital or emergency room readmissions were observed for patients that received COPD CARE, leading to the scaling of COPD CARE across multiple outpatient clinics. 5 In 2018, COPD CARE was recognized as a Gold Status Promising Practice by the VA Diffusion of Excellence Program, providing the opportunity to design, implement and evaluate a national program implementation package.  As a result, the service was expanded to one additional medical center in 2019. Recipients of COPD CARE were significantly less likely to have hospital and emergency department readmissions and significantly more likely to receive follow-up care from a pharmacist or primary care provider within 30 days of discharge. In 2020, the COPD CARE implementation package was revised with clinical note templates, quick-guides, and videos modeling examples of a COPD CARE visit. From August 2020 to August 2021, the implementation package was used to disseminate COPD CARE to 18 additional VA medical centers. To date, 20 medical centers across the Department of Veterans Affairs have completed the COPD CARE Academy and are working to adopt the COPD CARE delivery model.

The COPD CARE service demonstrates the impact of a team-based, coordinated care bundle delivered by integrating pharmacists as prescribers within the PCMH.



1. Quaderi SA, Hurst JR. The unmet global burden of COPD. Glob Heal Epidemiol Genomics. 2018;3:21-23. doi:10.1017/gheg.2018.1

2. Plan A. National Action Plan. J Sch Health. 2019;63(1):46-66. doi:10.1111/j.1746-1561.1993.tb06065.x

3. Mannino D, Yu T-C, Zhou H, Higuchi K. Effects of GOLD-Adherent Prescribing on COPD Symptom Burden, Exacerbations, and Health Care Utilization in a Real-World Setting. Chronic Obstr Pulm Dis J COPD Found. 2015;2(3):223-235. doi:10.15326/jcopdf.2.3.2014.0151

4. GOLD COMMITTEE. GOLD-REPORT-2021-v1.1-25Nov20_WMV.pdf. Published online 2021:12-19.

5. Portillo EC, Wilcox A, Seckel E, et al. Reducing COPD Readmission Rates: Using a COPD Care Service During Care Transitions. Fed Pract. 2018;35(11):30-36.