Collaborative Self-Management Support for Chronic Conditions
According to the Centers for Disease Control, chronic illness accounts for 7 out of every 10 deaths in the United States. Ninety million people are diagnosed with one or more chronic conditions. Twenty five million suffer severe limitations due to a chronic illness. Seventy-five percent of health care costs are related to chronic illness care. Finding effective strategies to prevent and treat chronic illness care is never more critical. Collaborative self-management support, based on the Chronic Care Model, is an approach that is showing promising results in reducing the impact of chronic illness on health and health care costs.
New Health Partnerships has created an online community. This website was designed collaboratively by and for clinicians, administrative leaders, patients, and families. It provides information, resources, best practice examples, and opportunities for discussion to support improved communication, self-management, support, and advocacy, particularly for individuals managing a chronic health condition.
Self-management support refers to the education and resources that are offered to individuals with chronic conditions to support them in building their confidence and competence to manage their condition. Health care providers work collaboratively with patients and their families to make decisions about their care. For people with chronic conditions this means making lifestyle changes as well as following through with treatment and medication regimens. For providers, it means partnering with the patient and family to create a plan of care.
Collaborative self-management support shifts care delivery from the traditional provider- or system-centered model to a patient- and family-centered approach. Patients, their families, and providers build a mutually respectful relationship where all respect each others' expertise, share information candidly, and build a shared understanding of the patients' and family members' goals, priorities, values, and needs as well as evidence-based clinical options. Together they create a plan that guides care in the clinical setting and at home.
Health care organizations will need to redesign or change the structures and practices within their organization in order to effectively adopt collaborative self-management support in chronic illness care. Recognizing the potential of this approach, leading foundations are supporting initiatives to bring about this transformation.
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A patient advisor actively participates in a Quality Allies Learning Session. |
The Institute for Healthcare Improvement (IHI) is coordinating a national multi-year initiative, funded by the Robert Wood Johnson Foundation, to improve care for individuals with chronic conditions in ambulatory settings. During the initial phase, six clinical practices were part of a Pilot Collaborative on Self-Management Support. During Phase Two, twenty ambulatory teams participated in the Quality Allies: Improving Care by Engaging Patients collaborative to test out improvements in collaborative self-management support. This initiative included patients and families on the national advisory committee for the project and on the faculty team. Each of the twenty teams recruited and prepared patients and families to serve as members of their improvement teams. The California HealthCare Foundation also provided funding and participated in Phase Two of this project. The third phase of this initiative, the New Health Partnerships Virtual Learning Collaborative, began in Spring 2007. Nine interdisciplinary teams are working to advance the practice of collaborative self-management support in various types of ambulatory settings. Patients and families are active members of each of these improvement teams. Patients and families are also members of the core faculty team.