The Supporting Patient Activation in Transition to Home Intervention
The Supporting Patient Activation in Transition to Home Intervention
This study evaluates if motivational interviewing sessions aiming to motivate recently
 discharged patients with either chronic obstructive pulmonary disease or congestive heart
 failure to be active in post-discharge self-management can reduce re-hospitalization rates.
Included patients transition to home will be bridged through a telephone-call from a patient
 activation coach two days post-discharge. The patients will thereafter get motivational
 interviewing sessions by the same patient activation coach with the the goal that the
 patients are motivated to the knowledge, skills and confidence needed to manage the four main
 activity areas: 1) medication management; 2) adhere to care plan/ follow-up visits according
 to the discharge plan; 3) recognize indications (symptoms/signs) that the condition is
 worsening and how to respond; and 4) contact and manage relations/encounters with health care
 providers. Patients in control group will receive standard care, i.e. discharge and follow-up
 as in normal procedures. The investigators will use a randomization in permuted blocks of 10
 intervention patients and 10 control patients included. To test the hypothesis that the
 re-hospitalizations rate is 15 % lower in the intervention group compared to the control
 group 242 patients (121 per group) are needed for power of 80% with the level of significance
 set to 5 % using two-sided chi-square.
Inclusion Criteria:

 -  Patients aged 18 years or older with chronic obstructive pulmonary disease or
 congestive heart failure admitted at a short-term medical ward and who are living in
 their private home.

 Exclusion Criteria:

 -  Diagnoses of dementia or cognitive impairment, and need of interpreter to participate
 in conversations.

 The exclusion criteria are related to the patients' possibilities to participate in the
 motivational interviewing sessions by phone.