INSPIRED COPD Outreach Program™ Change Package:
Implementing an INSPIRED Approach to Care for Patients Living with Advanced COPD


“ Before I had doubts whether I could go anywhere… [The INSPIRED program has] given me my life back ... ”
INSPIRED patient, Halifax, NS


Download the INSPIRED Change Package

A 75-year-old Halifax patient recalls what it felt like during an acute chronic obstructive pulmonary disease (COPD) exacerbation (AECOPD): “It’s panic time when it strikes. You can’t breathe, you’re gasping for air. It is unbelievable, until it happens to you.” Before enrolling in INSPIRED, he had five hospital visits within 14 months, and could not climb five stairs continuously. Since completing the program, he can ascend two flights of stairs and self-manage his symptoms well enough to go away on vacation. This is just one example of how INSPIRED has positively impacted patients.

This change package outlines all of the components of the INSPIRED COPD Outreach Program™ and provides resources, tips and a suggested measurement approach.

The components include:

  • Optimization of medications and an action plan for prescriptions
  • Continuity of care in hospital-to-home transitions
  • Individualized, coordinated and proactive care that includes:
  • Partnership building with community and allied healthcare support services
  • Monitoring and evaluation for quality assurance purposes


In Canada, COPD is the chronic disease most responsible for hospital admissions. It is a leading cause of morbidity and mortality, and is expected to become the third leading cause of death worldwide. In this country, AECOPDs account for more than $750-million a year in hospital-based costs – an estimate that does not include routine care. A nationwide Lung Association report card also gave most Canadian provinces poor or failing grades for COPD care.


INSPIRED was developed and implemented at the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia in 2010 as a way to improve care transitions from hospital-to-home for COPD patients and families following hospital discharge. The goal was to provide support to enable patients and families to better manage their advanced COPD at home, decrease their sense of isolation, distress and dependency on emergency department (ED) and inpatient healthcare services.

In addition to patients and families reporting improved experiences of care, feeling more confident in managing their symptoms, being willing to discuss goals of care and experiencing significant improvements in quality of care transitions from hospital to home, six-months after enrollment in the INSPIRED program in Halifax, 131 patients had 60% fewer ED visits, 63% fewer hospital admissions and 62% fewer hospital days (see Rocker & Verma, 2014). The reduction in hospitalizations translates into an estimated cost saving of $977,000 – more than three times the annual operating costs of the INSPIRED program. These reductions continued into the 12-month patient follow-up (93 patients) resulting in 52% fewer ED visits, 55% fewer hospital admissions and 61% fewer hospital days compared to 12 months prior to program enrollment. In Spring 2014, INSPIRED was recognized by Accreditation Canada with a “Leading Practice” designation, as a noteworthy example of high-quality leadership and service delivery in COPD care.

What this Change Package Offers

  • Implementing an INSPIRED approach to care for patients living with advanced COPD starts with CFHI’s change package, which outlines what INSPIRED is and facilitates clinical adoption and evaluation.
  • This package is intended to act as a process guide for healthcare providers and delivery-level organizations seeking to implement this innovation and improve care for people living with COPD. It provides a review of the INSPIRED interventions that are key to providing more holistic, accessible and patient-centred care for people living with advanced COPD.

What this Change Package Includes

  • INSPIRED COPD Outreach ProgramTM driver diagram: Provides a visual model of the theory of change behind the INSPIRED program. It breaks down the improvement goal into primary drivers (improvement areas that need to be addressed to achieve the outcome) and secondary drivers (specific interventions).
  • Key change concepts: The secondary drivers are further broken down into key change concepts that outline the elements of each intervention.
  • Relevant tools and resources.