Active Patient Support assists patients, who find it hard to cope with their challenges, to take better care of themselves and increase their quality of life.
The region has many especially elderly patients with chronic diseases such as COPD, heart disease and diabetes, or suffering from complicated diseases like cancer with frequent contacts to the healthcare system. Many of them find it hard to cope with their challenges. They lose overview. This has strong negative impacts on their quality of life.
The objective of the service Active Patient Support (APS) is to help patients to better manage their lives with illness through health coaching. They are given advice on how to cope with the illnesses themselves. The complex interaction of the health and care units involved in their pathway of treatment is explained to them, they are assisted in coordinating their health-related appointments, and they are encouraged to explore and accept public health and care offers available where relevant. The overall goal is to improve their coping skills and quality of life.
The service is tailored to the individual patient’s needs. It starts with a face-to-face dialogue where a specially trained nurse establishes a partnership with the patient to address individual health problems. Follow-up support and guidance is subsequently provided by telephone weekly or at other intervals for 6-9 months.
The main beneficiaries are citizens/patients with chronic and complex diseases. Others include close relatives (spouses, partners and children), friends, health and care staff – as well as the healthcare system in general.

Resources needed

Example. In 2019 the APS service provided support to 609 patients with a staff of ten specialised nurses and a manager. Yearly costs included salaries (≈ EUR 39,000 in total – Danish salary levels), office facilities in four locations in the region, and computer hardware and software.

Evidence of success

An analysis has been made of the results achieved in the pilot phase (2014-2016) involving 390 COPD patients. The conclusion was that the APS service had contributed to a statistically significant improved quality of life of patients supported. The analysis was based on the SF-36 tool for assessment of patient-reported physical and mental health. An analysis of the results for a larger patient group covered during 2017-2019 is in process. It also addresses health literacy and cost of service.

Difficulties encountered

At first, some patients find it difficult to acknowledge how the service can assist them in managing their lives of illness. Has been a challenge in recruitment of participants. The approach with patients and nurses acting as partners takes time for some patients to appreciate and fully utilize.

Potential for learning or transfer

Chronic diseases represent the major share of the burden of disease in Europe. Helping people with chronic diseases to live active and productive lives is of significant social and economic value. Many efforts are being made to prevent chronic diseases, but once they are a reality, there is a need to enable patients to live as normal lives as possible. Health coaching like the APS service is one type of health-related quality of life (HRQOL) measure. Research findings on health coaching in most cases point to improved quality of life (e.g. measured in reductions in unhealthy days - UHDs). This is also the case of the APS service. While additional research is warranted to create a more nuanced picture of the benefits of health coaching to tailor programmes, there already seems to be clear enough evidence to recommend this kind of service to other countries in Europe. APS in Region Zealand started in 2016. All other four Danish regions began implementing similar programmes in mid-2017.
Main institution
Region Zealand
Sjælland, Denmark (Danmark)
Start Date
January 2016
End Date


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