Patients who are less than 4 weeks post-exacerbation
(due to COPD or any of the comorbidities) or less than 6 weeks post-hospitalisation or -rehabilitation are considered unstable and their assessment will be delayed until they reach the defined level of stability. Before inclusion, symptoms of anxiety and depression will be assessed with the HADS in all eligible
patients. In case of a cut-off score of ≥11, we will integrate the anxiety and depression component in the patient's individual action plan. Other frequently existing comorbidities such as osteoporosis, metabolic syndrome, anaemia, and microalbuminuria
are unlikely to confuse the symptomatology of
COPD exacerbations as much as our selected comorbidities, so we have not included these comorbidities in our intervention. Finally, patients with cognitive dysfunction will be excluded.