Part 1: Create a detailed scenario in which a patient with frequent re-admissions for Chronic Obstructive Pulmonary Disease (COPD) is successfully integrated into a care plan that exhibits continuity of care from admission to successful discharge to home with follow-up visits and monitoring. 

Part 2: Your patient has transitioned home; however, during a follow-up visit you notice that the patient is having a mild exacerbation and you need to notify the patients doctor for possible admission. Create a detailed ISBAR report prior to calling the physician.