Self-management support for patients with chronic illness is a routine function of clinical care in many primary care organizations. This report describes models that have been successful in involving these patients in a well-planned and efficient way.
This paper explores ways that primary care organizations are making self-management support a routine function of clinical care for patients with chronic illness. Effective self-management support includes giving patients information, teaching disease-specific skills, negotiating healthy behavior change, providing training in problem-solving skills, assisting with the emotional impact of having a chronic condition, providing regular and sustained follow-up, and encouraging active participation in managing the disease.
Many early adopters of self-management support provided input for this paper, and the experiences of several are described in detail. The case studies include:
- UNITE Health Center in New York City, a medical assistant model
- Project Dulce in San Diego, a community health worker (promotora) model
- Mercy Clinics in Des Moines, Iowa, an RN model
- CareSouth Carolina, a culture change model
Additional case studies focus on telephone-based models of self-management support as well as behavioral health models.
The business case for self-management support is discussed in detail.
The complete report is available as a Document Download.