Abstract: Objective A community-based management pathway of "family-community-hospital" was constructed to provide theoretical basis for chronic disease management of COPD. Methods By using "Plan-Do-Check-Act" as the theoretical framework we designed"family-community-hospital" pathway for COPD. Fifteen experts in the field of clinical diagnosis and treatment,clinical nursing,community nursing,nursing management and nursing education in Tianjin were selected and two rounds of questionnaire consultations were conducted. The final pathway was completed by combining expert opinions and the index threshold screening method. Results The authority coefficient of experts was 0.90. The response rates of two rounds consultation were respectively 93.75% and 100%. The optimal management pathway of COPD in family-community-hospital was consisted of 6 first-level indicators and 21 second-level indicators. The first-level indicators included assessment,plan,action,evaluation,variation and feedback. The coordination coefficients were respectively 0.16 and 0.14. The score of the importance was up 3.5 points.The coefficient of variation was among 0.053 and 0.137. Conclusion The optimal management pathway of COPD with"family-community-hospital" has been proved to be scientific.

Key words: Pulmonary Disease,Chronic Obstructive, Patient Care Management, Community Health Services