Promoting Effective Self-Management Approaches to Improve Chronic Disease Care: Lessons Learned

Susan Baird Kanaan


This is archived content, for historical reference only.

Patient self-management aims to help improve chronic disease care and curb the escalating economic and public health impact of chronic illness. Through daily decisions about diet, exercise, self-measurement, and medications, people with chronic illness are encouraged to play the central role in determining the course of their diseases. However, to be successful, they need the support of their health care providers to make and sustain changes in these areas.

The California Health Care Foundation has determined that while many health care organizations are interested in helping their patients manage their chronic conditions, the organizations need new organizational capacity, clinical skills, and strategies to do so.

For this reason, the foundation led a two-year initiative in 2006 and 2007 to give health care organizations the training and tools to support their patients’ growth in self-management. The initiative focused on diabetes, which causes heavy use of health care services and which benefits from self-management strategies. CHCF awarded grants of $65,000 to 10 health care organizations around California, each with a significant number of low-income people among its patients. The grantee organizations were diverse in size, location, and resources, and included community health centers, Federally Qualified Health Centers (FQHCs), a county health department, and a medical practice in a large integrated delivery system. All showed a willingness to make permanent changes to integrate self-management support into care delivery.

This report provides a summary of the lessons learned by the organizations involved in this initiative, including successful strategies for self-management support, system design and patient flow, training, and measurement. Also available are examples of self-management plans in both English and Spanish.

The complete report is available under Document Downloads.

Also available for download, in English and Spanish, is the “My Diabetes Plan” tool, which providers can use to structure their conversations with patients about setting and meeting goals.