• Coastal COPD patients with limited literacy

• Elderly with inhaler misuse

• Patients with BMI<21

• Smoking COPD patients

• Patients with poor vaccine awareness

• Patients lacking exercise prescriptions

Jiali Chi Mei Hospital, a 341-bed regional teaching hospital with 788 staff, joined the NHI COPD Pay-for-Performance program in November 2018 and became the first regional hospital in Taiwan to receive Joint Commission COPD Disease Certification in December 2021. The team centers on "COPD AE Bundle Care" — an interdisciplinary model integrating pulmonology, case managers, smoking cessation educators, dietitians, rehabilitation, pharmacists, and community education to provide seamless outpatient-to-inpatient continuity. Features include IT alert systems, illustrated education materials, individualized exercise prescriptions, nutrition referral workflows, visual vaccine education, official LINE group, and a COPD knowledge website, extending care into communities, schools, and workplaces. In 2024, an AI personalized prognostic prediction model was implemented (3/6-month exacerbation, mortality, ventilator dependency). As of May2026: 345 enrolled patients (258 OPD, 87 inpatient); inhaler accuracy rose from 35.4% to 100%; 6-month smoking cessation rate 72.4%; flu vaccination rate 85%.

• Taiwan-first regional hospital with COPD certification

• Interdisciplinary COPD AE Bundle Care model

• IT-based enrollment/follow-up alert system

• Illustrated visual education and exercise prescription

• COPD knowledge website and LINE group

• AI personalized prognostic prediction model

• Total enrollment: 345

• Enrollment time: 17 → 5 minutes

• Education sheet usage: 0% → 100%

• 9 years in NHI improvement program

• Pulmonary rehabilitation＞90%

• Inhaler device assessment: 100%

• Smoking cessation counseling: 100%

• Nutritional assessment and education (BMI<21kg/m2) : 100%

• 6MWT execution rate: 100%

• Individualized exercise prescription: 100%

• Hospital stay reduced 1.3 days vs literature

• 28-day readmission improved 3.3%

• Enrollment accuracy: 100%

• Smoking referral rate: 100%

• Seamless cross-team care

• AI model supports clinical decisions

• Education satisfaction: 35% → 100%

• Significant CAT score improvement

• Significant mMRC dyspnea improvement

• Positive public feedback

• 100% cross-team professional rating

• Multiple media reports

• Compared with international literature (Chalder 2016) LOS and readmission better than international

• AI prognostic prediction model established

• Published paper on COPD with degenerative joint disease

• 2022 TCIA Regional Award, Silver Tower Award

• Pioneers regional hospital COPD care excellence

• Extends COPD care into communities/schools/workplaces

• Positive media coverage broadens social impact

• AI prediction model supports clinical decisions

• Promotes preventive care for high-risk coastal populations