The COPD Outreach Team at St. Paul's Hospital is a pilot project aimed at facilitating the transition from hospital to home for patients with COPD and assisting them to remain healthy and well at home or in their communities. The program emphasizes education and self-management, as well as ongoing monitoring to ensure discharged clients continue to do well at home. Clients enrolled in this initiative will be supported by an interdisciplinary team of health care professionals. The Team has demonstrated reductions in hospital readmissions as well as an improvement in communication between the hospital and community through their efforts. The team consists of Jane Burns, physiotherapist, Beth Hutchins, nurse educator and Alexis Ciuk, respiratory therapist.