Exclusion criteria are:
(1) terminal cancer, end stage of COPD or another serious disease with low survival rate (expected survival b12 months);
(2) other serious lung disease (e.g.α1-antitrypsin deficiency ; interstitial lung diseases);
(3) patients with cognitive impairment (Mini Mental State Examination (MMSE) b 24) ;
(4) patients who are currently enrolled in other randomized controlled trials or intensive case management programmes.