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Supporting Self-Management in Patients with Chronic Illness MARY THOESEN COLEMAN, M.D., PH.D., and KAREN S

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Supporting Self-Management in Patients with Chronic Illness MARY THOESEN COLEMAN, M.D., PH.D., and KAREN S Supporting Self-management in Patients with Chronic Illness MARY THOESEN COLEMAN, M.D., PH.D., and KAREN S. NEWTON, M.P.H. University of Louisville School of Medicine, Louisville, Kentucky Support of patient self-management is a key component of effective chronic illness care and improved patient outcomes. Self-management support goes beyond traditional knowledge-based patient education to include processes that develop patient problem-solving skills, improve self-efficacy, and support application of knowledge in real-life situa- tions that matter to patients. This approach also encompasses system- focused changes in the primary care environment. Family physicians can support patient self-management by structuring patient-physician interactions to identify problems from the patient perspective, making office environment changes that remove self-management barriers, and providing education individually and through available com- munity self-management resources. The emerging evidence supports the implementation of practice strategies that are conducive to patient self-management and improved patient outcomes among chronically ill patients. (Am Fam Physician 2005;72:1503-10. Copyright © 2005 American Academy of Family Physicians.) See editorial on global rise in life expectancy and interventions in individual nonmanaged page 1454. an increase in cultural and envi- care practices has yet to be determined.3,5-7 A ronmental risks such as smoking, review7 of 41 studies assessing interventions unhealthy diet, lack of physical to improve diabetes outcomes in primary A activity, and air pollution are associated with care revealed that adding patient-oriented an epidemic of chronic illness. Approxi- interventions can lead to improvements mately 120 million Americans have one or in outcomes such as glycemic control. In more chronic illnesses, accounting for 70 to 36 trials focused on adult asthma, self- 80 percent of health care costs. Twenty-five management (self-monitoring coupled with percent of Medicare recipients have four or medical review and a written action plan) more chronic conditions, accounting for produced greater reductions in nocturnal two thirds of Medicare expenditures.1,2 Most symptoms, hospitalizations, and emer- patients with chronic conditions such as gency department use than did usual care.8 hypertension, diabetes, hyperlipidemia, con- Another community-based group program, gestive heart failure, asthma, and depres- designed to increase self-efficacy among sion are not treated adequately, and the patients with diabetes, resulted in improved burden of chronic illness is magnified by the self-efficacy and A1C levels.9 Despite this fact that chronic conditions often occur as encouraging evidence, self-management is comorbidities.3 the least implemented and most challenging Physician support of patient self-manage- area of chronic disease management.10 ment is one of the key elements of a systems- Although the terms patient self-manage- oriented chronic care model.4 Increasing ment, self-management support, and patient evidence shows that self-management sup- education often are used interchangeably, port reduces hospitalizations, emergency they do not have the same meaning. Self- department use, and overall managed care management is the ability of the patient to costs, although the cost of self-management deal with all that a chronic illness entails, October 15, 2005 ◆ Volume 72, Number 8 www.aafp.org/afp American Family Physician 1503 SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References To support self-management, family physicians should address goal C 10 setting and problem solving, make office system changes, provide self-management education, and link the patient to community self- management programs. Motivational interviewing is recommended as an effective way to A 18 prevent relapse in alcohol dependence. Weekly follow-up phone calls by a nurse manager and monthly calls B 5 by a physician are recommended as a way to improve blood sugar control and weight loss in patients with diabetes. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evi- dence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 1435 or http://www.aafp.org/afpsort.xml. including symptoms, treatment, physical and relation of what is taught to the disease, and social consequences, and lifestyle changes.11 the theory underlying the goal (Table 1).13 With effective self-management, the patient The theory underlying patient education is can monitor his or her condition and make that increasing a patient’s knowledge about whatever cognitive, behavioral, and emo- a disease leads to behavioral change that tional changes are needed to maintain a improves clinical outcomes. An underlying satisfactory quality of life.11 Self-management theory of self-management education is that support is the process of making multi- self-efficacy, or the patient’s belief in his level changes in health care systems and the or her own ability to accomplish a specific community to facilitate patient self-manage- behavior or achieve a reduction in symp- ment.10,12 Patient education generally refers to toms, leads to improved clinical outcomes. knowledge-based instructions for a specific Self-management support expands the role disease. Self-management education differs of health care professionals from delivering from traditional patient education in what information to include helping patients build is taught, how problems are formulated, the confidence and make choices that lead to TABLE 1 Components of Patient Education and Self-management Education The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication. 1504 American Family Physician www.aafp.org/afp Volume 72, Number 8 ◆ October 15, 2005 Self-management Support TABLE 2 Steps to Support Self-management in Patients with Chronic Illness Physician actions restaurants). It may be useful for physicians Address health literacy issues and medical making this shift to remind themselves that, obstacles to self-management. for the patient, self-management is inevi- Identify problems from the patient’s table and already occurring.10,16 More specific perspective by asking provocative questions methods are discussed below, and summa- and listening to patient responses (Figure 1). rized in Table 2. Include goal-setting, action-planning, and problem-solving strategies to overcome MOTIVATIONAL INTERVIEWING barriers based on the patient’s immediate concerns. Motivational interviewing is an in-depth Link patients to community-based self- approach to decision making intended to management resources. help patients come to their own decisions Provide self-management education. by exploring their uncertainties. Practice changes The interviewer uses directive Physicians can support Follow up with patients systematically about questions and reflective listening self-management by focus- action plans and goals, in person, by phone, to encourage the patient to par- ing on helping patients or by e-mail. ticipate (Figure 1).17 This style Provide group visits that include self- of interview, asking the patient deal with the day-to-day management education. provocative questions and dis- problems of living with Schedule planned visits that allow time to chronic illness. address self-management tasks. cussing the responses, often can help uncover important self- management issues, and has been proven effective for preventing relapse in patients improved self-management and better out- with alcohol dependence.18 comes. Patient education typically is given by a health care professional; self-management IDENTIFYING BARRIERS can be taught and supported by health care A common barrier to successful self-man- professionals, office support staff, peer lead- agement is that chronic conditions often ers, and other patients. occur as comorbidities. Patients with chronic The self-management challenges for per- diseases who are asked to identify barri- sons with chronic conditions can be divided ers to self-management often cite examples into three types: medical management, such as aggravation of one condition by role management, and emotional manage- the symptoms or treatment of another, and ment.13-15 Physicians who want to provide problems created by multiple medication reg- increased support of their patients’ self- imens.16,19,20 Physicians can help patients set management are advised to address three goals that will affect real-life challenges, rather areas: structuring patient-physician inter- than disease-oriented goals. For example, actions to include goal-setting and prob- lem-solving strategies, making office system changes, and providing self-management Sample Provocative Questions for Use in Planned Visits education by linking patients to community self-management programs.10 What are you afraid might happen as a result of your [fill in condition: e.g., diabetes, asthma]? Practical Applications for Physicians Lots of patients have problems with medications. What problems have you had? There are many ways that physicians can Self-management decisions are “experiments” that will lead you to more translate this evidence for self-management effective and satisfying management of your [condition]. Tell me about support into daily practice. Primarily,
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