Kate Lorig

Self-management education: History, definition, outcomes, and mechanisms

Self-management has become a popular term for behavioral interventions as well as for healthful behaviors. This is especially true for the management of chronic conditions. This article offers a short history of self-management. It presents three self-management tasks—medical management, role management, and emotional management—and six self-management skills—problem solving, decision making, resource utilization, the formation of a patient-provider partnership, action planning, and self-tailoring. In addition, the article presents evidence of the effectiveness of self-management interventions and posits a possible mechanism, self-efficacy, through which these interventions work. In conclusion the article discusses problems and solutions for integrating self-management education into the mainstream health care systems.

EVIDENCE SUGGESTING THAT A CHRONIC DISEASE SELF-MANAGEMENT PROGRAM CAN IMPROVE HEALTH STATUS WHILE REDUCING HOSPITALIZATION: A RANDOMIZED TRIAL

OBJECTIVES This study evaluated the effectiveness (changes in health behaviors, health status, and health service utilization) of a self-management program for chronic disease designed for use with a heterogeneous group of chronic disease patients. It also explored the differential effectiveness of the intervention for subjects with specific diseases and comorbidities. METHODS The study was a six-month randomized, controlled trial at community-based sites comparing treatment subjects with wait-list control subjects. Participants were 952 patients 40 years of age or older with a physician-confirmed diagnosis of heart disease, lung disease, stroke, or arthritis. Health behaviors, health status, and health service utilization, as determined by mailed, self-administered questionnaires, were measured. RESULTS Treatment subjects, when compared with control subjects, demonstrated improvements at 6 months in weekly minutes of exercise, frequency of cognitive symptom management, communication with physicians, self-reported health, health distress, fatigue, disability, and social/role activities limitations. They also had fewer hospitalizations and days in the hospital. No differences were found in pain/physical discomfort, shortness of breath, or psychological well-being. CONCLUSIONS An intervention designed specifically to meet the needs of a heterogeneous group of chronic disease patients, including those with comorbid conditions, was feasible and beneficial beyond usual care in terms of improved health behaviors and health status. It also resulted in fewer hospitalizations and days of hospitalization.

Chronic disease self-management program: 2-year health status and health care utilization outcomes.

Objectives.To assess the 1- and 2-year health status, health care utilization and self-efficacy outcomes for the Chronic Disease Self-Management Program (CDSMP). The major hypothesis is that during the 2-year period CDSMP participants will experience improvements or less deterioration than expected in health status and reductions in health care utilization. Design.Longitudinal design as follow-up to a randomized trial. Setting.Community. Participants.Eight hundred thirty-one participants 40 years and older with heart disease, lung disease, stroke, or arthritis participated in the CDSMP. At 1- and 2-year intervals respectively 82% and 76% of eligible participants completed data. Main Outcome Measures. Health status (self-rated health, disability, social/role activities limitations, energy/fatigue, and health distress), health care utilization (ER/outpatient visits, times hospitalized, and days in hospital), and perceived self-efficacy were measured. Main Results. Compared with baseline for each of the 2 years, ER/outpatient visits and health distress were reduced (P <0.05). Self-efficacy improved (P <0.05). The rate of increase is that which is expected in 1 year. There were no other significant changes. Conclusions.A low-cost program for promoting health self-management can improve elements of health status while reducing health care costs in populations with diverse chronic diseases.

How should we define health

The WHO definition of health as complete wellbeing is no longer fit for purpose given the rise of chronic disease. Machteld Huber and colleagues propose changing the emphasis towards the ability to adapt and self manage in the face of social, physical, and emotional challenges

A review and synthesis of research evidence for self-efficacy-enhancing interventions for reducing chronic disability: implications for health education practice (part I).

Disability and poor quality of life attributable to chronic diseases such as arthritis, diabetes, and heart disease constitute challenging public health problems for American society. In the absence of any effective cure for these conditions, the secondary prevention of complications and improving quality of life and functional capacity through better disease self-management becomes critical and are key objectives of Healthy People 2010. The organizing focus of such disease self-management should be on improving coping, communication, and control by enhancing self-efficacy. Part I of this two-part article describes the common clinical features of chronic diseases and the diverse disease management strategies used for alleviating pain and preventing disability associated with these and reviews the role of self-efficacy as a theoretical framework for successful self-management interventions. Part II identifies and synthesizes the key research evidence for educational interventions designed to enhance individual self-efficacy perceptions and presents implications for practice in patient education.

Patients as partners in managing chronic disease: Partnership is a prerequisite for effective and efficient health care

General practice p 550 Education and debate p 569 When acute disease was the primary cause of illness patients were generally inexperienced and passive recipients of medical care. Now that chronic disease has become the principal medical problem the patient must become a partner in the process, contributing at almost every decision or action level. This is not just because patients deserve to be partners in their own health care (which, of course, they do) but also because health care can be delivered more effectively and efficiently if patients are full partners in the process. Today in the United States chronic disease is the major cause of disability, is the main reason why people seek health care, and consumes 70% of healthcare spending. The differences between acute and chronic diseases are seen in the box on the BMJ s website. With acute disease, the treatment aims at return to normal. With chronic disease, the patients life is irreversibly changed. Neither the disease nor its consequences are static. They interact to create illness patterns requiring continuous and complex management. Furthermore, variations in patterns of illness and treatments …

Arthritis Self-Management Studies: A Twelve-Year Review

The Arthritis Self-Management Program (ASMP) is a program that has been developed and studied over 12 years. This paper is a summary of the results of these studies. Several conclusions have been reached. 1. The ASMP in randomized trails improves behaviors, self-efficacy, and aspects of health status. 2. Formal reinforcement does not appear to improve the long-term outcomes of the ASMP. 3. The effects of the ASMP last for as long as 4 years without formal reinforcement. 4. The improvement gains by the ASMP participants have importance both clinically and in terms of cost savings. 5. The mechanism by which the ASMP affects health status appears to be more closely linked to changes in self-efficacy than to changes in behaviors

Internet-Based Chronic Disease Self-Management A Randomized Trial

Background:The small-group Chronic Disease Self-Management Program (CDSMP) has proven effective in changing health-related behaviors and improving health statuses. An Internet-based CDSMP was developed to reach additional chronic-disease patients. Objectives:We sought to determine the efficacy of the Internet-based CDSMP. Design:We compared randomized intervention participants with usual-care controls at 1 year. We compared intervention participants with the small-group CDSMP at 1 year. Subjects:Nine-hundred fifty-eight patients with chronic diseases (heart, lung, or type 2 diabetes) and Internet and e-mail access were randomized to intervention (457) or usual care control (501). Measures:Measures included 7 health status variables (pain, shortness of breath, fatigue, illness intrusiveness, health distress, disability, and self-reported global health), 4 health behaviors (aerobic exercise, stretching and strengthening exercise, practice of stress management, and communication with physicians), 3 utilization variables (physician visits, emergency room visits, and nights in hospital), and self-efficacy. Results:At 1 year, the intervention group had significant improvements in health statuses compared with usual care control patients. The intervention group had similar results to the small-group CDSMP participants. Change in self-efficacy at 6 months was found to be associated with better health status outcomes at 1 year. Conclusions:The Internet-based CDSMP proved effective in improving health statutes by 1 year and is a viable alternative to the small-group Chronic Disease Self Management Program.

Patient Self-Management: A Key to Effectiveness and Efficiency in Care of Chronic Disease

Halsted Holman, MDa The present health care system is neither effective nor efficient. The dominant Kate Lorig RN DrPH3 reason for this is a contradiction between the principle problem confronting the system?chronic disease?and the systems methods of operating, which were designed for acute disease. Resolution of the contradiction requires a different practice of health care, with new roles for the patients, for physicians and other health professionals, and for health services. Until the middle of the last century, acute disease was the major health problem in the United States. Then chronic disease began to emerge as the central health care issue. Now, chronic disease is the major cause of disability, the principle reason why patients visit physicians, and the reason for 70% of health care expenditures.1,2 The present health care system, designed early in the last century to cope with acute disease, did not change when chronic disease became the major issue. As a consequence, discontinuity and fragmen tation of care are widespread. Technology is often applied unnecessarily. Com munity and home-based care are poorly developed. Costs mount without obvi ous commensurate benefits for patients. And a large segment of the population is unable to obtain appropriate health care. Why is this so? The answer begins to emerge when we examine the differ ences between acute and chronic disease, as outlined in Tables 1 and 2. Among the many differences, the most crucial are: There is no cure for chronic disease; instead, management over time is essential.

Self-Management: Enabling and Empowering Patients Living With Cancer as a Chronic Illness

With recent improvements in the early detection, diagnosis, and treatment of cancer, people with cancer are living longer, and their cancer may be managed as a chronic illness. Cancer as a chronic illness places new demands on patients and families to manage their own care, and it challenges old paradigms that oncologys work is done after treatment. As a chronic illness, however, cancer care occurs on a continuum that stretches from prevention to the end of life, with early detection, diagnosis, treatment, and survivorship in between. In this article, self‐management interventions that enable patients and families to participate in managing their care along this continuum are reviewed. Randomized controlled trials of self‐management interventions with cancer patients and families in the treatment, survivorship, and end‐of‐life phases of the cancer care continuum are reviewed, and the Chronic Care Model is presented as a model of care that oncology practices can use to enable and empower patients and families to engage in self‐management. It is concluded that the need for a common language with which to speak about self‐management and a common set of self‐management actions for cancer care notwithstanding, oncology practices can now build strong relationships with their patients and formulate mutually agreed upon care plans that enable and empower patients to care for themselves in the way they prefer. CA Cancer J Clin 2011.