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Chronic Disease Self-Management

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Abstract

Successful management of chronic disease requires the patient to carry out treatments recommended by healthcare professionals. Patients must be well-informed collaborators in their own care. Using a shared decision-making process, health professionals help the patient make informed decisions that achieve agreed-upon goals by providing education, appropriate care recommendations, expert advice, and support. Self-management prepares patients to care for their health, keeping wellness as a focus. It involves techniques that enhance empowerment and self-efficacy in the setting of the office or home. Support comes from the provider, the community, and peers.

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References

  1. Ward BW. Multiple chronic conditions among US adults: a 2012 update. Prev Chronic Dis. 2014;11.

    Google Scholar 

  2. Lorig KR, Holman HR. Self-management education: history, definition, outcomes, and mechanisms. Ann Behav Med. 2003;26(1):1–7.

    Article  PubMed  Google Scholar 

  3. Britt E, Hudson SM, Blampied NM. Motivational interviewing in health settings: a review. Patient Educ Couns. 2004;53(2):147–55.

    Article  PubMed  Google Scholar 

  4. B P. The shifting perspective model of chronic illness. J Nurs Scholarsh. 2001 (First Quarter:21–26.).

    Google Scholar 

  5. Corbin JM, Strauss A. Unending work and care: managing chronic illness at home: Jossey-Bass; 1988.

    Google Scholar 

  6. Bourbeau J. Clinical decision processes and patient engagement in self-management. Dis Manag Health Outcomes. 2008;16(5):327–33.

    Article  Google Scholar 

  7. Bandura A. Self-efficacy: the exercise of control. New York: Freeman; 1997.

    Google Scholar 

  8. Disler R, Gallagher R, Davidson P. Factors influencing self-management in chronic obstructive pulmonary disease: an integrative review. Int J Nurs Stud. 2012;49(2):230–42.

    Article  CAS  PubMed  Google Scholar 

  9. Barr VJ, Robinson S, Marin-Link B, Underhill L, Dotts A, Ravensdale D, et al. The expanded chronic care model: an integration of concepts and strategies from population health promotion and the chronic care model. Healthc Q. 2003;7(1).

    Google Scholar 

  10. Bodenheimer T, Chen E, Bennett HD. Confronting the growing burden of chronic disease: can the US health care workforce do the job? Health Aff. 2009;28(1):64–74.

    Article  Google Scholar 

  11. Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean?(or it takes at least two to tango). Soc Sci Med. 1997;44(5):681–92.

    Article  CAS  PubMed  Google Scholar 

  12. Sheridan SL, Harris RP, Woolf SH, Force SD-MWotUPST. Shared decision making about screening and chemoprevention: a suggested approach from the US preventive services task force. Am J Prev Med. 2004;26(1):56–66.

    Article  PubMed  Google Scholar 

  13. Makoul G, Clayman ML. An integrative model of shared decision making in medical encounters. Patient Educ Couns. 2006;60(3):301–12.

    Article  PubMed  Google Scholar 

  14. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff. 2008;27(3):759–69.

    Article  Google Scholar 

  15. Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361–7. PubMed PMCID: 3445676

    Article  PubMed  PubMed Central  Google Scholar 

  16. Agency for Healthcare Research and Quality. The SHARE Approach 2015. Available from: http://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/index.html.

  17. Heisler M. Building peer support programs to manage chronic disease: seven models for success. Available from: http://www.chcf.org/publications/2006/12/building-peer-support-programs-to-manage-chronic-disease-seven-models-for-success.

  18. Fisher EB. Peer support in health care and prevention: cultural, organizational, and dissemination issues. Annu Rev Public Health. 2014.;35;35:363–83.

    Article  PubMed  Google Scholar 

  19. Dahlgren G, Whitehead M. Policies and strategies to promote social equity in health. Stockholm: Institute for Future Studies; 1991.

    Google Scholar 

  20. Dennis C-L. Peer support within a health care context: a concept analysis. Int J Nurs Stud. 2003;40(3):321–32.

    Article  PubMed  Google Scholar 

  21. Heisler M. Building peer support programs to manage chronic disease: seven models for success. Oakland: California Health Care Foundation; 2006.

    Google Scholar 

  22. Heisler M. Different models to mobilize peer support to improve diabetes self-management and clinical outcomes: evidence, logistics, evaluation considerations and needs for future research. Family practice. 2009:cmp003.

    Google Scholar 

  23. Fisher EB, Boothroyd RI, Coufal MM, Baumann LC, Mbanya JC, Rotheram-Borus MJ, et al. Peer support for self-management of diabetes improved outcomes in international settings. Health Aff. 2012;31(1):130–9.

    Article  Google Scholar 

  24. Aujoulat I, d’Hoore W, Deccache A. Patient empowerment in theory and practice: polysemy or cacophony? Patient Educ Couns. 2007;66(1):13–20.

    Article  PubMed  Google Scholar 

  25. Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA. 2002;288(19):2469–75. PubMed PMID: 12435261

    Article  PubMed  Google Scholar 

  26. Collins C, Rochfor A. Promoting self-management and patient empowerment in primary care, primary care in practice 2016.

    Google Scholar 

  27. Powers MA, Bardsley J, Cypress M, Duker P, Funnell MM, Fischl AH, et al. Diabetes self-management education and support in type 2 diabetes a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Diabetes Educ. 2015;41(4):417–30.

    Article  PubMed  Google Scholar 

  28. Kaplan B, Brennan PF. Consumer informatics supporting patients as co-producers of quality. J Am Med Inform Assoc. 2001;8(4):309–16.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Catherine HY, Bahniwal R, Laupacis A, Leung E, Orr MS, Straus SE. Systematic review and evaluation of web-accessible tools for management of diabetes and related cardiovascular risk factors by patients and healthcare providers. J Am Med Inform Assoc. 2012;19(4):514–22.

    Article  Google Scholar 

  30. Free C, Phillips G, Galli L, Watson L, Felix L, Edwards P, et al. The effectiveness of mobile-health technology-based health behaviour change or disease management interventions for health care consumers: a systematic review. PLoS Med. 2013;10(1):e1001362.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Petrie KJ, Perry K, Broadbent E, Weinman J. A text message programme designed to modify patients’ illness and treatment beliefs improves self-reported adherence to asthma preventer medication. Br J Health Psychol. 2012;17(1):74–84.

    Article  PubMed  Google Scholar 

  32. De Jongh T, Gurol-Urganci I, Vodopivec-Jamsek V, Car J, Atun R. Mobile phone messaging for facilitating self-management of long-term illnesses. Cochrane Libr. 2012.

    Google Scholar 

  33. Whittaker R, McRobbie H, Bullen C, Borland R, Rodgers A, Gu Y. Mobile phone-based interventions for smoking cessation. Cochrane Libr. 2012.

    Google Scholar 

  34. Shaw R, Bosworth H. Short message service (SMS) text messaging as an intervention medium for weight loss: a literature review. Health Informatics J. 2012;18(4):235–50.

    Article  PubMed  PubMed Central  Google Scholar 

  35. O’Reilly GA, Spruijt-Metz D. Current mHealth technologies for physical activity assessment and promotion. Am J Prev Med. 2013;45(4):501–7.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Park LG, Howie-Esquivel J, Dracup K. A quantitative systematic review of the efficacy of mobile phone interventions to improve medication adherence. J Adv Nurs. 2014;70(9):1932–53.

    Article  PubMed  Google Scholar 

  37. Horvath T, Azman H, Kennedy GE, Rutherford GW. Mobile phone text messaging for promoting adherence to antiretroviral therapy in patients with HIV infection. Cochrane Libr. 2012.

    Google Scholar 

  38. Hall AK, Cole-Lewis H, Bernhardt JM. Mobile text messaging for health: a systematic review of reviews. Annu Rev Public Health. 2015;36:393–415.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Stead LF, Perera R, Lancaster T. A systematic review of interventions for smokers who contact quitlines. Tob Control. 2007;16(Suppl 1):i3–8.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Lancaster T, Stead L, Silagy C, Sowden A. Effectiveness of interventions to help people stop smoking: findings from the Cochrane Library. BMJ: Br Med J. 2000;321(7257):355.

    Article  CAS  Google Scholar 

  41. Lancaster T, Stead LF. Self-help interventions for smoking cessation. Cochrane Libr. 2005.

    Google Scholar 

  42. Prochaska JO, Di Clemente CC. Toward a comprehensive model of change. Treating addictive behaviors: Springer; 1986. p. 3–27.

    Google Scholar 

  43. Crespo R, Shrewsberry M. Factors associated with integrating self-management support into primary care. Diabetes Educ. 2007;33(Supplement 6):126S–31S.

    Article  PubMed  Google Scholar 

  44. Hill-Briggs F, Yeh HC, Gary TL, Batts-Turner M, D’Zurilla T, Brancati FL. Diabetes problem-solving scale development in an adult. Afr Am Sample Diabetes Educ. 2007;33(2):291–9. PubMed PMID: 17426304

    Article  Google Scholar 

  45. DeWalt DA, Broucksou KA, Hawk V, Brach C, Hink A, Rudd R, et al. Developing and testing the health literacy universal precautions toolkit. Nurs Outlook. 2011;59(2):85–94.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Rickheim PL, Weaver TW, Flader JL, Kendall DM. Assessment of group versus individual diabetes education: a randomized study. Diabetes Care. 2002;25(2):269–74. PubMed PMID: 11815494

    Article  PubMed  Google Scholar 

  47. Newman S, Steed L, Mulligan K. Self-management interventions for chronic illness. Lancet. 2004;364(9444):1523–37.

    Article  PubMed  Google Scholar 

  48. Steiner BD, Denham AC, Ashkin E, Newton WP, Wroth T, Dobson LA. Community care of North Carolina: improving care through community health networks. Ann Family Med. 2008;6(4):361–7.

    Article  Google Scholar 

  49. Millner W, Rollnick S. Motivational interviewing: preparing people for change. New York: Guilford Press; 2002.

    Google Scholar 

  50. Morton K, Beauchamp M, Prothero A, Joyce L, Saunders L, Spencer-Bowdage S, et al. The effectiveness of motivational interviewing for health behaviour change in primary care settings: a systematic review. Health Psychol Rev. 2015;9(2):205–23. PubMed PMID: 26209209

    Article  PubMed  Google Scholar 

  51. Abramowitz SA, Flattery D, Franses K, Berry L. Linking a motivational interviewing curriculum to the chronic care model. J Gen Intern Med. 2010;25(Suppl 4):S620–6. PubMed PMCID: 2940440

    Article  PubMed  Google Scholar 

  52. Martins RK, McNeil DW. Review of motivational interviewing in promoting health behaviors. Clin Psychol Rev. 2009;29(4):283–93.

    Article  PubMed  Google Scholar 

  53. Asthma GIf. Global strategy for asthma management and prevention.: Global Initiative for Asthma; 2015 [updated April 2015; cited 2015]. Available from: http://www.ginasthma.org/local/uploads/files/GINA_Report_2015_Aug11.pdf.

  54. Centers for Disease C. National Health Interview Survey Data: Asthma 2013 [updated September 9, 201413 Nov 2015]. Available from: http://www.cdc.gov/asthma/nhis/2013/table3-1.htm.

  55. Moorman J, Rudd R, Johnson C, King M, Minor P, Bailey C, et al. National surveillance for asthma – United States, 1980–2004. MMWR Surveill Summ. 2007;56(8):1–54.

    PubMed  Google Scholar 

  56. Association AL. Trends in asthma morbidity and mortality 2012 [updated September 15, 2015; cited 2015]. Available from: http://www.lung.org/assets/documents/research/asthma-trend-report.pdf.

  57. Skrepnek G, Skrepnek S. Epidemiology, clinical and economic burden, and natural history of chronic obstructive pulmonary disease and asthma. Am J Manag Care. 2004;10(5 Suppl):S129–S38.

    PubMed  Google Scholar 

  58. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academies Press; 2001.

    Google Scholar 

  59. Gandhi PK, Kenzik KM, Thompson LA, DeWalt DA, Revicki DA, Shenkman EA, et al. Exploring factors influencing asthma control and asthma-specific health-related quality of life among children. Respir Res. 2013;14:26. PubMed PMCID: 3599064. Epub 2013/02/26. eng

    Article  PubMed  PubMed Central  Google Scholar 

  60. Wilson SR, Strub P, Buist AS, Knowles SB, Lavori PW, Lapidus J, et al. Shared treatment decision making improves adherence and outcomes in poorly controlled asthma. Am J Respir Crit Care Med. 2010;181(6):566–77. PubMed PMID: 20019345. PMCID: 2841026

    Article  PubMed  Google Scholar 

  61. Tapp H, Shade L, Mahabaleshwarkar R, Taylor Y, Ludden T, Dulin MF. Results from a pragmatic prospective cohort study of adults and children: shared decision making improves outcomes for children with asthma (accepted for publication). J Asthma. 2016.

    Google Scholar 

  62. Tapp H, McWilliams A, Ludden T, Kuhn L, Taylor Y, Alkhazraji T, et al. Comparing traditional and participatory dissemination of a shared decision making intervention (ADAPT-NC): a cluster randomized trial. Implement Sci. 2014;9(1):158. PubMed PMID: 25359128. PMCID: 4219101

    Article  PubMed  PubMed Central  Google Scholar 

  63. Rivera-Spoljaric K, Halley M, Wilson SR. Shared clinician-patient decision-making about treatment of pediatric asthma: what do we know and how can we use it? Curr Opin Allergy Clin Immunol. 2014;14(2):161–7. PubMed PMID: 24553296. Epub 2014/02/21. eng

    Article  PubMed  Google Scholar 

  64. Charles C, Gafni A, Whelan T. Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Soc Sci Med. 1999;49(5):651–61. PubMed PMID: 10452420

    Article  CAS  PubMed  Google Scholar 

  65. Tapp H, Kuhn L, Alkhazraji T, Steuerwald M, Ludden T, Wilson S, et al. Adapting community based participatory research (CBPR) methods to the implementation of an asthma shared decision making intervention in ambulatory practices. J Asthma. 2014;51(4):380–90. PubMed PMID: 24350877. PMCID: 4002642. Epub 2013/12/20. eng

    Article  PubMed  PubMed Central  Google Scholar 

  66. Tapp H, Hebert L, Dulin M. Comparative effectiveness of asthma interventions within a practice based research network. BMC Health Serv Res. 2011;11:188. PubMed PMCID: 3176175. Epub 2011/08/19. eng

    Article  PubMed  PubMed Central  Google Scholar 

  67. Mowrer JL, Tapp H, Ludden T, Kuhn L, Taylor Y, Courtlandt C, et al. Patients’ and providers’ perceptions of asthma and asthma care: a qualitative study. J Asthma. 2015;15:1–8. PubMed PMID: 25975701

    Google Scholar 

  68. National Asthma Education and Prevention Program. Expert panel report-3: guidelines for the diagnosis and management of asthma Bethesda, MD: National Institutes of Health, National Heart, Lung, and Blood Institute. NIH Publication No. 08–4051; 2007.

    Google Scholar 

  69. Apter AJ, Wan F, Reisine S, Bender B, Rand C, Bogen DK, et al. The association of health literacy with adherence and outcomes in moderate-severe asthma. J Allergy Clin Immunol. 2013;132(2):321–7. PubMed PMID: 23591273. PMCID: 3745278

    Article  PubMed  PubMed Central  Google Scholar 

  70. Lorig K, Ritter PL, Turner RM, English K, Laurent DD, Greenberg J. A diabetes self-management program: 12-Month outcome sustainability from a nonreinforced pragmatic trial. J Med Internet Res. 2016;18(12).

    Google Scholar 

  71. Lorig K, Center SPE. Stanford self-management programs effectiveness and translation. Inst Med. 2004.

    Google Scholar 

  72. Stanford University School of Medicine. Chronic disease self-management Program Web site. 02/20/2017. Available from: http://patienteducation.stanford.edu/programs/cdsmp.html.

  73. Heisler M. Overview of peer support models to improve diabetes self-management and clinical outcomes. Diabetes Spectr. 2007;20(4):214–21.

    Article  Google Scholar 

  74. Page J, Weisner S. Peer-to-peer learning in the self-management of chronic disease. NC Med J. 2011;72(5):398.

    Google Scholar 

  75. Ansell J, Jacobson A, Levy J, Völler H, Hasenkam JM. Guidelines for implementation of patient self-testing and patient self-management of oral anticoagulation. International consensus guidelines prepared by International Self-Monitoring Association for Oral Anticoagulation. Int J Cardiol. 2005;99(1):37–45.

    Article  PubMed  Google Scholar 

  76. Association AD. Economic costs of diabetes in the US in 2012. Diabetes Care. 2013;36(4):1033–46.

    Article  Google Scholar 

  77. Boyle JP, Thompson TJ, Gregg EW, Barker LE, Williamson DF. Projection of the year 2050 burden of diabetes in the US adult population: dynamic modeling of incidence, mortality, and prediabetes prevalence. Popul Health Metrics. 2010;8(1):29.

    Article  Google Scholar 

  78. Ahn S, Basu R, Smith ML, Jiang L, Lorig K, Whitelaw N, et al. The impact of chronic disease self-management programs: healthcare savings through a community-based intervention. BMC Public Health. 2013;13(1):1141.

    Article  PubMed  PubMed Central  Google Scholar 

  79. Healy SJ, Black D, Harris C, Lorenz A, Dungan KM. Inpatient diabetes education is associated with less frequent hospital readmission among patients with poor glycemic control. Diabetes Care. 2013;36(10):2960–7.

    Article  PubMed  PubMed Central  Google Scholar 

  80. Duncan I, Ahmed T, Li QE, Stetson B, Ruggiero L, Burton K, et al. Assessing the value of the diabetes educator. Diabetes Educ. 2011;37(5):638–57.

    Article  PubMed  Google Scholar 

  81. Norris S, Lau J, Smith S, Schmid C, Engelgau M. Original articles-epidemiology/health services/psychosocial research-self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic control. Diabetes Care. 2002;25(7):1159–71.

    Article  PubMed  Google Scholar 

  82. Robbins JM. Nutritionist visits, diabetes classes, and hospitalization rates and charges: the urban diabetes study. Diabetes. 2007;56.

    Google Scholar 

  83. Kenny P, Lancsar E, Hall J, King M, Chaplin M. The individual and health sector costs of asthma: the first year of a longitudinal study in New South Wales. Aust N Z J Public Health. 2005;29(5):429–35. PubMed PMID: 16255444. Epub 2005/11/01. eng

    Article  PubMed  Google Scholar 

  84. Barnes P, Jonsson B, Klim J. The costs of asthma. Eur Respir J. 1996;9(4):636–42.

    Article  CAS  PubMed  Google Scholar 

  85. Wheeler JR. Can a disease self-management program reduce health care costs?: the case of older women with heart disease. Med Care. 2003;41(6):706–15.

    PubMed  Google Scholar 

  86. Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS. Impact of medication adherence on hospitalization risk and healthcare cost. Med Care. 2005;43(6):521–30.

    Article  PubMed  Google Scholar 

  87. Van Woensel W, Roy PC, Abidi SR, Abidi SSR, editors. A mobile and intelligent patient diary for chronic disease self-management. MedInfo; 2015.

    Google Scholar 

  88. Eysenbach G. The law of attrition. J Med Internet Res. 2005;7(1):e11.

    Article  PubMed  PubMed Central  Google Scholar 

  89. Valdez RS, Holden RJ, Novak LL, Veinot TC. Transforming consumer health informatics through a patient work framework: connecting patients to context. J Am Med Informatics Assoc. 2014:amiajnl-2014-002826.

    Google Scholar 

  90. Gervera K, Graves BA. Integrating diabetes guidelines into a telehealth screening tool. Perspectives in health information management. 2015;12(Summer).

    Google Scholar 

  91. Darkins A, Kendall S, Edmonson E, Young M, Stressel P. Reduced cost and mortality using home telehealth to promote self-management of complex chronic conditions: a retrospective matched cohort study of 4,999 veteran patients. Telemed e-Health. 2015;21(1):70–6.

    Article  Google Scholar 

  92. Miller AS, Cafazzo JA, Seto E. A game plan: gamification design principles in mHealth applications for chronic disease management. Health Informatics J. 2016;22(2):184–93.

    Article  PubMed  Google Scholar 

  93. Merolli M, Gray K, Martin-Sanchez F. Health outcomes and related effects of using social media in chronic disease management: a literature review and analysis of affordances. J Biomed Inform. 2013;46(6):957–69.

    Article  PubMed  Google Scholar 

  94. Battersby M, Von Korff M, Schaefer J, Davis C, Ludman E, Greene SM, et al. Twelve evidence-based principles for implementing self-management support in primary care. Joint Comm J Q Patient Saf. 2010;36(12):561–70.

    Google Scholar 

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Authors and Affiliations

  1. Carolinas Healthcare System, Department of Family Medicine, Charlotte, NC, USA

    Hazel Tapp

  2. UNC Charlotte, Public Health Sciences, Charlotte, NC, USA

    Michael Dulin

  3. UNC Gillings School of Global Public Health, Chapel Hill, NC, USA

    Marcus Plescia

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  1. Hazel Tapp
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  2. Michael Dulin
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Correspondence to Hazel Tapp .

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Editors and Affiliations

  1. Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA

    Timothy P. Daaleman

  2. Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA

    Margaret R. Helton

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Tapp, H., Dulin, M., Plescia, M. (2018). Chronic Disease Self-Management. In: Daaleman, T., Helton, M. (eds) Chronic Illness Care. Springer, Cham. https://doi.org/10.1007/978-3-319-71812-5_3

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