Action plans in telephone-based self-management support among patients at risk of hospitalization - A process evaluation of the Danish RCT Proactive Health Support (PaHS)

Objective: Self-management support (SMS) aims to improve management of chronic diseases. While SMS core components are frequently documented, person-centered action plans and goal achievement is unknown. The aim of this study was to explore predictors of goal achievement in action plans during the Proactive Health Support study (PaHS). Method: PaHS is a Danish randomized controlled trial of telephone-based SMS for patients at risk of hospitalization. The present study includes the trial intervention group with completed action plans as part of the trial process evaluation. The association between baseline characteristics of action plans and subsequent goal achievement were analyzed with logistic regression. Results: In this study, 1400 participants with a total of 2363 action plans were included. The results show higher goal achievement when the patients' goals were related to management of disease and treatment compared to health behavior. Furthermore, a stronger feeling of empowerment was associated with subsequent goal achievement. Conclusion: Goal achievement in PaHS was generally high. The probability of goal achievement was highest with goals related to disease management, everyday-life management, and treatment. Higher baseline empowerment was associated with increased goal achievement. Practice Implications: SMS should focus on treatment management and patients with lower levels of active engagement and motivation.