Lessons Learned from a Multi-Site QI Project Focused on Identifying Best Practices for COPD Transitions of Care Intervention-Slides

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The REVISITS study, funded by NIH in 2020 and led by Valerie G. Press and collaborators, is a multi-site quality improvement (QI) project designed to identify best practices for implementing Chronic Obstructive Pulmonary Disease (COPD) transitions of care (TOC) programs across diverse U.S. hospitals. COPD affects 16 million Americans and is characterized by frequent acute care revisits due to care transition failures, leading to lung function decline and higher mortality. Despite this, few successful COPD TOC programs exist.<br /><br />The study's purpose is to evaluate tailored COPD care transition interventions delivered either virtually or in-person, with mentored support or co-design approaches, aiming to reduce preventable acute COPD revisits. The project has three specific aims: (1) pre-implementation contextual assessments to understand baseline practices and plan site-specific TOC program bundles; (2) a one-year implementation phase evaluating comparative effectiveness of different intervention delivery and support models; and (3) a two-year post-implementation phase assessing program sustainability.<br /><br />REVISITS uses a multidisciplinary team involving clinicians, a patient collaborator, human-centered design (HCD) experts, and implementation scientists applying the Consolidated Framework for Implementation Research (CFIR) and HCD’s 5A framework to capture system-level factors and individual experiences. This integrated approach ensures interventions are customized to local settings while incorporating patient and clinician perspectives.<br /><br />The mentored implementation model pairs local site champions with national experts for guidance, while co-design sessions—facilitated by Onda Collective—engage patients and staff collaboratively to refine interventions.<br /><br />Lessons learned highlight the importance of early multi-level stakeholder engagement, using contextual assessments to identify gaps and resources, and tailoring implementation strategies to site-specific needs. The study emphasizes integrating evidence-based practices with systematic, user-centered design to enhance COPD TOC programs, offering a scalable framework for hospitals to improve care transitions and patient outcomes in chronic disease management.

Keywords

REVISITS study

COPD

Chronic Obstructive Pulmonary Disease

transitions of care

quality improvement

implementation science

human-centered design

mentored implementation

co-design

hospital care programs