Comprehensive care plan-a method of managing home rehabilitation care for patients with COPD

Chronic obstructive pulmonary disease (COPD) is a chronic disease with long duration and repeated attacks that is difficult to cure and requires long-term treatment and care. We propose a new patient-centered chronic disease management - comprehensive care plan, which aims to provide personalized care guidance services and comprehensive, proactive and effective management of patients with different severity of COPD. Firstly, we combine the support vector machines (SVM), decision tree (DT) and random forest (RF) algorithm to make the comprehensive evaluation of patient's condition and sent the evaluation report to the clinician to determine the severity of patient. And then, the system will provide the patient with a personalized and reasonable home rehabilitation comprehensive care plan based on the severity of patient. The model of comprehensive evaluation has been validated using data collected from 35 patients that have been marked by physicians and achieved encouraging results. At the same time, the patients with hypercapnia and the severity C/D of COPD were taken as an example to give their home care plan.