The investigators' goal for this project is to evaluate the feasibility, acceptability, and actual usage of a program of care for patients with COPD recently discharged after an acute exacerbation. The program of care includes virtual pulmonary rehabilitation, integrated care, and remote clinical monitoring.

The investigators' goal for this project is to evaluate the feasibility, acceptability, and actual usage of a multimodal, individualized program of care for patients with COPD recently discharged from hospital with an acute exacerbation. The program will combine elements of existing standards of care at two institutions, Toronto Grace Health Centre and University Health Network, with emerging technologies.

The investigators want to determine whether the program is considered appropriate and useful to both patients and health care providers, and whether it is feasible to implement. The investigators also want to determine whether it is feasible to conduct a large-scale randomized control trial of the program. The investigators will also explore whether each intervention reduces re-admissions to hospital.

Inclusion Criteria:

• Referred to either Virtual Pulmonary Rehabilitation or Remote Clinical Monitoring at Toronto Grace Health Centre after discharge from UHN hospital with an AECOPD as defined by the clinical team

Exclusion Criteria:

• Pulmonary condition other than COPD as the main respiratory disease such as bronchiectasis or asthma
• Projected life expectancy ≤ 2 months , as determined by the clinical team
• Significant cognitive impairment and absence/inability of a family caregiver to consent and to follow study processes

The UHN research team (principal investigator, research coordinator and other delegated research staff) will have access to all source data and documents.

A dataset will be created with de-identified data from RCM. We will seek broad consent from participants for the future unspecified use of this data. This is in line with TCPS2 and CIHR funding guidelines to ensure data generated from this study is available to other researchers both in Canada and outside to inform improve patient, population and systems outcomes.

The TGHC and UHN clinical teams will have access to PHI to conduct VPR and Integrated Care, and for clinical escalation when required from RCM.

The UHN, TGHC, and U of T research teams will have access to anonymized data for analysis purposes.

Data will become available after study completion and for up to 5 years.

Data will be stored and analyzed on the secure UHN server. De-identified data will be analyzed by trained study personnel at the University of Toronto.