Eligibility Criteria:
Inclusion Criteria:
* Persons with a hospital contact within the last year caused by ≥ 1 of the following diagnoses: heart diseases (DI110, DI130, DI132, DI50), connective tissue diseases (DD86, DM05, DM06, DM08, DM09, DM30, DM31, DM32, DM33, DM34, DM35, DM36), pulmonary diseases (DJ40, DJ41, DJ42, DJ43, DJ44, DJ45, DJ46, DJ47, DJ60, DJ61, , DJ62, DJ63, DJ64, DJ65, DJ66, DJ67, DJ684, DJ701, DJ703, DJ841, DJ842, DJ843, DJ848, DJ849, DJ920, DJ961, DJ982, DJ983) or diabetes (DE10, DE11, DE14) Or
* Persons ≥ 18 years and ≥ three unplanned hospital admissions in the last six months Or
* Persons ≥ 65 years with a preventable hospital admission (predefined diagnoses: dehydration, constipation, lower respiratory tract infections, urinary tract infections, gastroenteritis, fractures, nutrition deficiency anemia, social causes and pressure ulcers) or a readmission (within 30 days)
Exclusion Criteria:
* Selected psychiatric diagnoses: substance abuse disorder (DF1), schizophrenia (DF2) or dementia (DF00, DF01, DF02, DF03, DF051)
* Metastatic cancer (DC77, DC78, DC79, DC80)
* Assisted living Facility
* Documented terminal illness or life expectancy \< one year
* Assessment of dementia
* Major surgery planned within 6 months
* Hearing impairment
* Not speaking Danish
* Cognitive impairment
* Substance abuse, that impairs adherence
* No telephone
* Receiving similar trial intervention
* Other (including intervention not suitable)