JMIR Publications

ABSTRACT

Background:

Community-based management of exacerbations in high-risk patients with chronic obstructive respiratory diagnoses remains a major challenge. Hybrid care interventions, combining digital support with in-person, patient-centered care, have shown potential to reduce unplanned hospitalizations. However, an efficacy-effectiveness gap has been observed.

Objective:

To co-design the core components of a hybrid care intervention for the preventive management of exacerbations in high-risk patients with chronic obstructive respiratory conditions, generating insights to guide sustainable adoption in routine clinical practice.

Methods:

In the Integrated Health District of Barcelona-Esquerra (AISBE, 520 k citizens), four Plan-Do-Study-Act (PDSA) co-design cycles, each lasting six months, were conducted using a mixed-methods approach during the two-year follow-up (2024–2025) of a cohort of 205 high-risk patients with chronic obstructive pulmonary disease (COPD) or severe asthma, following the corresponding disease-specific consensus guidelines.

Results:

The operationalization of the three core components of hybrid care: i) nurse-led in person care, ii) personalization of the intervention, and iii) advanced digital support was achieved. Moreover, clinical applicability and stakeholders’ acceptance of the approach for management of these patients in clinically stable conditions and during exacerbations were achieved.

Conclusions:

The intervention rollout requires emphasis on: (i) alignment with local care pathways and information systems, (ii) clear role definition and escalation procedures across care tiers, and (iii) adaptation of the digital layer to patients’ capabilities, including pragmatic support for those with limited digital literacy. The study provides guidance for site deployment. Its large-scale adoption still requires implementation tailoring and demonstration of healthcare value generation. Clinical Trial: NCT06421402