Winter 2008 Edition

February 22, 2008

Patients with chronic conditions must manage and cope with their illness every day. In order to manage their conditions, patients need to acquire and master many skills, including: monitoring their condition; taking medications and administering treatments; evaluating and managing symptoms; making adjustments in physical activity and diet, coping with the emotional aspects of having a chronic condition; and learning out how to overcome obstacles to performing important social roles as workers, students or members of a family. Simply providing information, writing prescriptions, offering information and making referrals to educational programs are not enough to help patients manage all of these aspects of having a chronic condition. Research has demonstrated that didactic educational programs alone are not sufficient to achieve improve self-management. On the other hand, there is substantial research evidence indicating that patients who become more actively engaged in managing their condition are not only are more confident; they also achieve better clinical and functional outcomes.

According to the Institute of Medicine, self-management support is accomplished by systematically using education and supportive interventions to increase patients' skills and confidence in managing their health problems. This definition of self-management support implies that no one clinician is responsible for insuring that patients are able to become effective self-managers. Rather, systems are needed to help clinical teams to provide self-management support to patients and/or family members. Self-management support is not an event or a course or a program; it is a process that recurs over the course of a patient’s illness. Over time, with the assistance of their clinical care team, patients gradually develop all the skills and competencies needed to address the challenges of having a chronic condition.

Research has indicated that successful self-management support interventions include the following key elements:

• patient-centered approaches that build trust, shared understanding and strong provider-patient relationships;
• individualized assessment of patient needs, values and preferences;
• collaborative goal setting and action planning;
• skill building, problem-solving;
• linkage to community resources and programs; and
• repeated follow-up contacts

Thus, in order to provide effective self-management support, clinicians need to develop specific skills or competencies in each of these elements. Though not every clinician need become expert in these core competencies, those clinicians who are primarily responsible for self-management support need training to help them do this well. Moreover, as noted previously, clinical systems are needed to help clinical teams to efficiently deliver SMS within the context and flow of clinical care. Particularly in primary care settings, teamwork is needed to share the responsibility and burden of providing self-management support across team members. Thus, for example, in some settings medical assistants will engage the patient and complete assessments of needs and preferences for self-management goal; a primary provider will collaborate with the patient to set a specific goal; and a nurse or health educator will develop a more specific action plan and provide follow-up to review progress towards goals. This may require system redesign or adoption of innovative ways to integrate self-management support into chronic care visits.

Health care teams have developed several useful tools and resources to enhance the process of self-management support. These include assessment tools, goal-setting and action planning forms, and educational materials to help patients understand the value of participating in self-management. Tools for evaluating patients’ experience with self-management support are quite useful as teams strive to improve care. When incorporated into electronic medical records or other information systems, these tools can also be used to document and keep track of patient progress and as prompts for both team members and patients.

New Health Partnerships is a Robert Wood Johnson Foundation-funded project that has assisted helping health care organizations to enhance their approach to self-management support. See www.newhealthpartnerships.org for more information as well as tools, resources and innovative strategies developed by teams that participated in this project.

Michael G. Goldstein, M.D.
Associate Director, Institute for Healthcare Communication
Adjunct Professor, Alpert Medical School of Brown University
Faculty Chair, New Health Partnerships Learning Community

References:
1. Adams, K., Corrigan, J., & Committee on Identifying Priority Areas for Quality Improvement, I. o. M. (2003). Priority Areas for National Action: Transforming Health Care Quality. Washington, DC: National Academies Press.
2. Bodenheimer, T., K. MacGregor, et al. (2005). Helping Patients Manage Their Chronic Conditions, California Health Care Foundation: 1-25.
3. Fisher, E. B., C. A. Brownson, et al. (2005). "Ecological Approaches to Self-Management: The Case of Diabetes." American Journal of Public Health 95: 1523-1535.
4. Glasgow, R. E., C. L. Davis, et al. (2003). "Implementing practical interventions to support chronic illness self-management." Jt Comm J Qual Saf 29(11): 563-74..
5. Heisler, M., Vijan, S., Anderson, R. M., Ubel, P. A., Bernstein, S. J., & Hofer, T. P. (2003). When do patients and their physicians agree on diabetes treatment goals and strategies, and what difference does it make? J Gen Intern Med, 18(11), 893-902.
6. Hibbard, J. H., Mahoney, E. R., Stockard, J., & Tusler, M. (2005). Development and testing of a short form of the patient activation measure. Health Serv Res, 40(6 Pt 1), 1918-1930.
7. Lorig, K. R., & Holman, H. R. (2003). Self-management education: history, definition, outcomes, and mechanisms. Ann Behav Med, 26(1), 1-7.
8. Norris, S. L., Engelgau, M. M., & Narayan, K. M. V. (2001). Effectiveness of Self-Management Training in Type 2 Diabetes: A systematic review of randomized controlled trials. Diabetes Care, 24(3), 561-587.

The views expressed in this article are those of the author and do not imply endorsement by The Robert Wood Johnson Foundation or the Health e-Technologies Initiative.