PurposeTo explore how persons living with COPD experience transitions related to health, self-management, and follow-up from the healthcare services.Patients and methodsThis study is part of a participatory research project. Six males and five females living with COPD, with a COPD assessment test score of 21–29, participated; all the participants were living at home. Data were collected in qualitative research interviews and analyzed using qualitative content analysis highlighting the participants’ experiences.ResultsThe findings showed two main themes: “The struggle to keep going” and “The need for continuity and competent facilitation”. The participants reported complex health transitions, with changes in roles and function, demanding exacerbations and critical events, and challenges with learning needed self-management. They expressed a great need for and had great benefit from, education, rehabilitation, and follow-up in their management of everyday life. Not all received offers in line with current guidelines.ConclusionIn-depth knowledge of patients’ experienced COPD transitions offers clinicians guidance for the timing and quality of follow-up services. Life with COPD entails challenging transitions in health and self-management. Good rehabilitation and follow-up from the healthcare services are needed throughout the disease trajectory. Participation in self-management education and rehabilitation that include psychosocial aspects may facilitate health-enhancing transitions and improve self-management skills. Experienced lack of competence and flexibility among healthcare providers hinders trust and collaboration. Access to stable and competent follow-up in the primary health services may facilitate cohesive services and collaborative self-management.

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