Sustaining a pharmacist-led COPD transition of care service in the rural context: a qualitative review of multilevel stakeholder perspectives from two Veterans Affairs medical centers.

Introduction: Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of morbidity and mortality globally, and rural patients are at higher risk for poor COPD health outcomes. The United States National Institutes of Health (NIH) has issued a call for innovative care delivery models to address this gap in COPD care quality in rural communities. This paper explores the perspective of healthcare teams at two rural VA medical centers sustaining an innovative interprofessional COPD care delivery model, COPD Coordinated Access to Reduce Exacerbations (CARE). Methods: This qualitative evaluation was conducted at two rural VA medical centers in the Southeast and Midwest regions of the US. Eleven semi-structured interviews with diverse clinical stakeholders were conducted including: facility leaders, hired pharmacists, clinical pharmacists, nurse care managers, primary care providers, and referral champions. The Practical Robust Implementation and Sustainability Model (PRISM) was applied to develop interview guides and informed data analysis. Interviews were transcribed and a mixed inductive-deductive approach was used for data analysis, involving iterative coding and consensus-building among five evaluators to identify emerging themes. Results: Five overarching themes emerged as key facilitators of COPD CARE sustainment including (1) leadership support, (2) value alignment, (3) service institutionalization, (4) service adaptation, and (5) interprofessional collaboration. Notably, clinical pharmacists were described as filling care gaps in these under-resourced facilities. Conclusion: This evaluation demonstrated the impact of clinical pharmacists serving as prescribers in improving COPD management in rural settings. The sustainment factors identified can be utilized to inform the expansion of similar, team-based healthcare programs across rural settings.