A Hybrid Care Intervention for High-Risk Patients With Chronic Obstructive Respiratory Disorders: Mixed Methods Co-Design Study

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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 efficacy to reduce unplanned hospitalizations in controlled trials. However, an efficacy-effectiveness gap remains, indicating the complexities of its deployment and sustainable adoption in real-world scenarios. Objective: This study aimed 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: Four plan-do-study-act (PDSA) co-design cycles were conducted, using a convergent mixed methods approach, during the 2-year follow-up (2024-2025) of a cohort of 205 high-risk patients pertaining to two different clinical programs: (1) the community-based program included multimorbid patients with chronic obstructive pulmonary disease (COPD), asthma, or bronchiectasis from the Integrated Health District of Barcelona-Esquerra (AISBE, 520 k citizens) and (2) the Severe Asthma Program included patients with severe asthma. In all cases, patients were managed following the corresponding disease-specific consensus guidelines. The specific aims of each PDSA cycle were: PDSA-1, patients' profiling and applicability of technological tools; PDSA-2, definition of clinical aspects of the hybrid care intervention and refinement of technology; PDSA-3, evaluation of a consolidated version of the hybrid care intervention; and PDSA-4, final refinements. Results: At the end of PDSA-3 (August 2025), the operationalization of the three core components of hybrid care-(1) nurse-led in-person care, (2) personalization of the intervention, and (3) advanced digital support-was achieved. The main study outcome was established through consensus among all key stakeholders on two aspects: (1) applicability of the hybrid care intervention for management of these patients in clinically stable conditions and during exacerbations in the real-world setting and (2) a well-defined strategy for its short-term deployment and sustainable site adoption. Conclusions: The intervention rollout requires emphasis on (1) alignment with local care pathways and information systems, (2) clear role definition and escalation procedures across care tiers, and (3) adaptation of the digital layer to patients' capabilities, including pragmatic support for those with limited digital literacy. The co-design process enabled the operationalization of a hybrid care intervention integrating nurse-led management, personalization of care, and advanced digital support. Stakeholders reached consensus regarding its applicability and implementation strategy. Future real-world implementation studies are needed to evaluate its effects on clinical outcomes, health care use, patient experience, and health care value generation.

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