Form 1 Blueprint Handout

OMB# 0925-0766

Exp. 4/30/2023

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COPD National Action Plan Collaboration and Tracking System — Preliminary Model

Welcome!

Please share your activity or initiative in support of the National Action Plan. Report only one activity per form submission.

1. 
   Name of the activity

2. Primary contact for this activity

Name

Organization

(for this activity)

Role in organization

City/Town

State/Province

Email Address

Phone Number

3. Which best describes you or your organization?

Advocacy organization/non-profit Health professional organization Health care provider

Industry

Federal, state, or local government agency Academic institution

Policymaker

Other (please describe)

Briefly describe your activity and how it contributes to the goals and objectives of the COPD National Action Plan.

4. 
   Summary (max 1500 characters)

5. 
   Include any links where people can learn more (websites, social media, journal articles, etc.).

6. Which goal of the National Action Plan does this activity best align with? While an organization might address multiple goals, each individual activity usually focuses most strongly on one. If this activity has a strong focus on more than one goal, please choose a primary and up to two secondary goals.

	Primary		Secondary
1: Empower people with COPD, their families, and caregivers to recognize and reduce the burden of COPD.
2: Improve the prevention, diagnosis, treatment, and management of COPD by improving the quality of care delivered across the health care continuum.
3: Collect, analyze, report, and disseminate COPD-related public health data that drive change and track progress.
4: Increase and sustain research to better understand the prevention, pathogenesis, diagnosis, treatment, and management of COPD.
5: Translate national policy, educational, and program recommendations into research and public health care actions.

Items 7-11 list objectives of each goal. Please select only objectives corresponding to the goal(s) you selected above, then continue on page 5.

7. Goal 1: Empower people with COPD, their families, and caregivers to recognize and reduce the burden of COPD.

If you chose this goal and your activity addressed specific objectives, please select all that apply.

Increase public awareness of the risk factors and symptoms of COPD so that earlier diagnosis of symptomatic individuals becomes the norm

Increase the effectiveness and variety of outreach communication campaigns and activities that utilize evidence-based approaches to raise awareness of COPD, particularly among those at high risk, and help people diagnosed with COPD manage the disease

Expand opportunities to increase COPD awareness across the public-private spectrum

8. Goal 2: Improve the prevention, diagnosis, treatment, and management of COPD by improving the quality of care delivered across the health care continuum.

If you chose this goal and your activity addressed specific objectives, please select all that apply.

Develop, disseminate, and maintain unified, multidisciplinary, and patient-centric national guidelines for COPD that are accessible and easy to follow

Develop a unified, multidisciplinary educational curriculum for health care professionals, including primary health care providers, using harmonized clinical practice guidelines

Develop, in accordance with clinical quality measures, a clinical decision tree and other tools to enable high-quality care for people with COPD

Develop and encourage the use of a written, patient-centric COPD management plan tool, with appropriate cultural and health literacy considerations, which can be customized with input from the patient's health care provider(s)

Improve access to care for people with COPD, particularly for those in hard-to reach areas

9. Goal 3: Collect, analyze, report, and disseminate COPD-related public health data that drive change and track progress.

If you chose this goal and your activity addressed specific objectives, please select all that apply.

Enhance and optimize our capacity to collect and aggregate data from multiple sources, including at local, regional, and national levels, and turn them into actionable information.

Facilitate dissemination of data and analyses. Report the prevalence of COPD in accordance with the requirements of public health and health care organizations

10. Goal 4: Increase and sustain research to better understand the prevention, pathogenesis, diagnosis, treatment, and management of COPD.

If you chose this goal and your activity addressed specific objectives, please select all that apply.

Help expand, coordinate, and optimize COPD research efforts

Improve methods for earliest detection and diagnosis and develop effective strategies for preventing the onset and progression of COPD

Define and characterize the pathogenesis of COPD heterogeneity

Develop personalized medicine for COPD based on the pathogenesis and clinical heterogeneity

Promote research that can lead to strategies that help prevent the onset and progression of COPD and improve the quality of COPD care and management

11. Goal 5: Translate national policy, educational, and program recommendations into research and public health care actions.

If you chose this goal and your activity addressed specific objectives, please select all that apply.

Put into action prevention strategies that are proven effective in addressing the 80 percent of COPD deaths due to smoking

Create a collaborative official entity that implements, prioritizes, and tracks activities in accordance with the COPD National Action Plan's goals and objectives

Identify and publicize funding opportunities that advance the implementation of the COPD National Action Plan Develop and implement COPD quality measures into national care delivery

Strengthen the public health infrastructure for addressing COPD

12. Which audience(s) did your activity serve? Choose all that apply.

Patients

Caregivers, family members

At-risk populations (history of smoking, workplace exposure to lung irritants, alpha-1 antitrypsin deficiency)

General public

Other (please describe)

Health professionals Employers Researchers Policymakers

13. Did your activity focus on any of the following groups? Choose all that apply.

	Hispanic		Men
	Non-Hispanic American Indian or Alaska Native		Women
	Non-Hispanic Asian or Pacific Islander
	Non-Hispanic Black
	Non-Hispanic White		Other (please describe below)

14. Which best describes your activity? Choose all that apply.

Patient education

Event

Campaign

Healthcare delivery

Material or product (indicate type — print, audio, visual, etc. — under other)

Provider education

Research Service Support group Training

Other (please describe)

Timing of your activity

15. 
    When did it start? (Month and year)

16. When did it stop, or is it ongoing?

Ongoing

Stop date (Month and year)

What area(s) of the country does your activity cover?

17. Geographic location (Choose all that apply) 18. Type of area (Choose all that apply)

	National		Urban
	Regional (multi-state; indicate states: _________________________________)		Suburban
	State (indicate state: ________________)		Rural
	Local (indicate state: ________________)
	Other (please describe below)

19. Setting in which your activity is implemented (choose all that apply)

Community Health care Home

Workplace Online

Other (please specify)

19. If this activity was a collaborative effort, please list the other entities involved.

We worked alone

We worked with the following organization(s) or individual(s)

19. Please describe how much this activity cost and its funding sources.

19. What impact has your activity had so far? (Include quantitative data if available, such as analytics, number of attendees or enrollees, quantities distributed or downloaded, etc.)

19. 
    What advice or lessons learned do you have for anyone considering a similar activity?

20. 
    What role did the COPD National Action Plan play in helping you develop the activity (e.g., provide ideas, lead to new collaborations or funding, etc.)?

19. Would you be interested in highlighting this activity more broadly with other COPD stakeholders?

Yes No

Thank you for contributing to the COPD National Action Plan Collaboration and Tracking System.

9

Draft — February 6, 2020