More than 10 years after publication, international guidelines remain poorly implemented. To better implement them, we need to develop new strategies adapted to the expectations of patients and health professionals outside hospital settings and to ensure better outpatient follow up in the community. We developed a bilingual education programme including a brochure designed to support an interdisciplinary health care network and measured hospitalisations (H), work absenteeism (WA), emergency visits (EV), asthma medication (AM) and quality of life (QL Juniper) before and 12 months after the intervention. All QL scores improved significantly in comparison with pre-intervention values. Health service use decreased dramatically when comparing the 12 months prior to and after the intervention(H: 35-8%, WA: 39-14%, EV: 88-53%). The final cost/benefit ratio of the programme was 1.96. Interdisciplinary implementation strategy of patient education is cost-effective, improves quality of life for asthmatics, and reduces strain on health services. Such a health care network does not require an expensive infrastructure and is better adapted to the reality and competences of clinical practice.

The evaluation demonstrated the feasibility and acceptability of the programme and confirmed the relevance of mixed method process evaluation to adjust and improve programme implementation. The introduction of multidisciplinary teams in a context characterised by fragmentation of care was identified as the main challenge in the programme implementation and could not be achieved as expected. Despite this area for improvement, patients' feedback and early effectiveness results confirmed the benefits of COPD integrated care programmes emphasising self-management education.

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