1. Stanford Chronic Disease Self-Management Model
Application in a Community Health Worker Program
Underwritten partially by a grant from MedTAPP HCA
Joan Thoman, PhD, RN, CNS, CDE
Pamela Rutar, EdD, RN, CNE
Cleveland State University School of Nursing
November 17, 2016

2. This session is about:
The Stanford Chronic Disease Self-Management Model
The application to a Community Health Worker Program

3. Impacts of Chronic Disease
Chronic disease will increase 300% by 2049
Chronic disease results in pain, debilitation, disability, dependence, lost physical function, and less mobility
Chronic diseases include: heart disease, cancer, stroke, arthritis, asthma, lung disease, cancer, diabetes, hypertension, osteoporosis, multiple sclerosis, Parkinson’s disease…
Stanford University Patient Education Center,

4. Financial Reality - Rising costs…
Chronic disease costs: 75-95% of health care expenditures!
By 2030: Anticipated increase in healthcare costs tied to chronic disease, 25% to 54%
Partnership for Solutions: Better Lives for People with Chronic Conditions, WA State, Health Affairs, 2005, 24 (1) 80-92, National Council on Aging

5. People With Chronic Disease Report…
Significantly reduced productivity
Living with less income
Accomplishing less
Spending more time in bed sick
Having poor mental health
LStanford University Patient Education Center , Lorig, K. 2003, National Council on Aging

6. What is self-management?
“The individual’s ability to manage the symptoms, treatment, physical and social consequences and lifestyle changes inherent in living with a chronic condition.”
Barlow goes on to say:
Efficacious self-management encompasses ability to monitor the condition and to effect cogitive, behavioral and emotional responses necessary to maintain a satisfactory quality of life.
It is a dynamic, continuous process of self-regulation.
Stanford University Patient Education Center,
Barlow, 2002.

7. Self-Management Benefits Patients…
Builds confidence (self-efficacy) to perform 3 tasks
- Disease management
- Role Management
- Emotional Management
Focuses on improved health status and appropriate health care utilization
Self Efficacy is a combination of confidence level and knowledge to achieve something, i.e. one may have the confidence but not the knowledge.
Disease Management : monitoring, recording and responding to symptoms.
Role Management: partnerships that include taking an active role in planning care and responsibility in keeping to the plan.
Emotional Management: managing the emotional impact that the disease has on their life, family, social and economical
Quality of life: focus on quality of life by improving their health status and appropriate use of resources

8. Self-Management Differs From Patient Education
- Manage life with disease
- Increase skills & self-confidence
- Problem solve and make decisions
Patient Education
- Change behaviors
- Increase knowledge
- Use specific tools (e.g., Care Plans)
A chronic disease may never be cured. We are looking to improve quality of life.

9. Patient ed. vs Self-mgmt.
Information and skills are taught Usually disease-specific Assumes that knowledge creates behavior change Goal is compliance Health care professionals are the teachers
Skills to solve pt. Identified problems are taught Skills are generalizable Assumes that confidence yields better outcomes Goal is increased self- efficacy Teachers can be professionals or peers
Both patient education and SMS are necessary.
Some aspects of patient education work well, some do not. Information is necessary and skills must be taught.
Knowledge does not create behavior change, and compliance is not a useful goal.
Adapted from Bodenheimer, JAMA 2002;288:2469
Norris et al. Effectiveness of self-management training in type 2 diabetes, Diabetes Care 2001;24:

10. Self-Management Also Encompasses
The patient and health professional working together.
Often involves the family.
An holistic approach to care (i.e., medical and psycho-social components of a condition).
Pro-active and adaptive strategies that aim to empower the individual.
The other side of the self-management relationship involves the healthcare provider. Their responsibilities include:
Working with the patient as different but equal partners. The healthcare provider is like an expert consultant regarding disease and treatments. The patient is the expert in how the disease is effecting him/ her personally, day-to-day. Health decisions need to be made together, in consideration of the disease, and the day-to-day effect it is having.
Acknowledging that there is more to the patient than the disease, and that the disease effects more than the patient’s body. Listen for other interventions that may be required, even if they are not directly linked to the disease, eg, social supports (is their caretaker getting any respite?, does the client they have any social networks?), other conditions that are effecting the patient’s daily living (deafness, incontinence). Etc
Responsible for supporting the whole person, not a ‘condition’.

11. Why is self-management so important? What is different?
Clinical outcomes are dependent on patient actions. Patient self-management is inevitable. The provider’s role is to be in partnership with the patient Professionals are experts about diseases, patients are experts about their own lives.
Everything that the clinical team does can improve processes, like testing rates or exam rates. Almost everything that is a true outcome, like symptom control, HbA1c, functional status is dependent on the patient taking the medication or altering their lifestyle.
Lorig: “It is impossible not to self-manage.” One can do it better, or worse.
Each part of the health care team brings expertise to the interaction. In the past, the provider’s expertise was dominant.
Need to develop truly collaborative care.
Bodenheimer T, Lorig K, Homan H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA 2002;288:

12. Chronic Disease Self-Management Assumptions
Patients with different chronic diseases have similar self-management problems and disease-related tasks.
Patients can learn to take day-to-day responsibility for their diseases.
Confident, knowledgeable patients practicing self-management will experience improved health status and use fewer health resources.
Stanford University Patient Education Center,
Lorig and Holeman 2003
Most people have more then one chronic illness

13. Self-Management Framework
Patients accept responsibility to manage or co- manage their own disease conditions.
Patients become active participants in a system of coordinated health care, intervention and communication.
Patients are encouraged to solve their own problems with information, but not orders, from professionals.
Stanford University Patient Education Center, National Council on Aging

14. Self-Management Skills
Problem-solving
Decision-making
Resource Utilization
Formation of a patient- provider partnership
Action-planning
Self-tailoring
Stanford University Patient Education Center, Lorig and Holeman 2003

15. Chronic Disease Self-Management Means…
Taking care of your illness (using medicines, exercise, diet, technology, physician partnership)
Carrying out normal activities (employment, chores, social life)
Managing emotional changes (anger, uncertainty about the future, changed expectations and goals, and depression)
It means having a combination of …
SKILLS, SUPPORT, PRACTICE and CONFIDENCE
Six principles of Self Management
1. Know your condition.
2. Be actively Involved in decision making with your healthcare provider.
3. Follow the care plan developed with your healthcare provider.
4. Monitor symptoms associated with the condition(s) and take appropriate action to respond and cope with the symptoms.
5. Manage the physical, emotional and social Impact of the condition(s) on your life.
6. Adopt a Lifestyle that promotes health and does not worsen the symptoms or the condition’s impact.

16. Clinical Information Systems Self- Management Support
Chronic Care Model
Community
Health System
Resources and Policies
Health Care Organization
Clinical Information Systems
Self- Management Support
Delivery System
Design
Decision
Support
Prepared,
Proactive
Practice Team
Informed,
Activated
Patient
Productive
Interactions
You are here.
Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly. 1999;7(3):56-66.
Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA 2002 Oct 16; 288(15):
Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A., Improving chronic illness care: translating evidence into action. Health Aff (Millwood) Nov-Dec;20(6):64-78.
Improved Outcomes

17. Self-Management in CCM
Personal Action Plan
1. List specific goals in behavioral terms
2. List barriers and strategies to address barriers
3. Specify Follow-up Plan
4. Share plan with practice team and patient’s social
support
ASSESS :
Beliefs, Behavior & Knowledge
ADVISE :
Provide specific
Information about
health risks and
benefits of change
AGREE:
Collaboratively set
goals based on patient’s
interest and confidence
in their ability to change
the behavior
ASSIST :
Identify personal
barriers, strategies, problem-solving
techniques and
social/environmental
ARRANGE :
Specify plan for
follow-up (e.g., visits,
phone calls, mailed
reminders
This diagram draws on the 5 A’s that some of you may be familiar with from smoking cessation brief counseling.
(Start at the top and go around the figure, reviewing each A.)
The central activity is the creation of a Personal Action Plan.
Glasgow RE, et al (2002) Ann Beh Med 24(2):80-87
Glasgow RE, et al (2002) Ann Beh Med 24(2):80-87

18. Chronic Disease Self- Management Program (CDSMP) …the Stanford Model
Developed by Stanford University’s patient education program
Structured w/~15 participants in a six-week series of workshops
Participative instruction with peer support
Designed to enhance medical treatment
Outcome-driven: impacts show potential for reduced or avoided costs
Evidence-based: a tested model (intervention) that has demonstrated results

19. Stanford’s CDSMP is Evidence-based
Found to truly benefit targeted populations.
Demonstrated it does not cause harm.
Demonstrated it does not waste resources.
National Council on Aging,

20. The Stanford CDSMP Model Why these techniques work…
Peer educators
Constant modeling
Active problem-solving
Formal brainstorming
Goal-setting
Action planning
National council on Aging,
Peer educators – workshop leaders “share” techniques. Not a “sage on a stage!”

21. CDSMP Content P Content/Week 1 2 3 4 5 6
Overview of self-management and chronic health conditions P
Making an action plan
Relaxation / Cognitive symptom management
Feedback / Problem solving
Anger / Fear / Frustration
Fitness / Exercise
Better breathing
Fatigue
Nutrition
Advance directives
Communication
Medications
Making treatment decisions
Depression
Informing the healthcare team
Working with your healthcare professional
Future plans

22. Participant’s Learn How to Manage the Symptom Cycle
Disease
Fatigue
Tense Muscles
VICIOUS
CYCLE
Depression
Stress/Anxiety
Anger/Frustration/Fear

23. Participant’s Learn and Practice Action Planning
Something YOU want to do
Reasonable
Behavior-specific
Answer the questions: What? How much? When? How often?
Confidence level of 7 or more
Examples:
I will manage my weight gain problem by cutting back on after dinner snacks by eating ½ of an apple instead of cookies. My confidence level is 8.
I will go to bed by 10:00 PM every night to ensure a good night of sleep. My confidence level is 8.
I will walk to and from the mailbox Monday through Saturday at noon to get started back on some regular physical activity. My confidence level is 7.
I will read a chapter in my new book each night before going to bed to help relax for sleep. My confidence level is 9.

24. The Stanford Model: Content… “meets the test of common sense”
Techniques to deal with frustration, fatigue, pain, and isolation.
Exercises/activities for maintaining and improving strength, flexibility, and endurance.
Medication management.
Approaches for improving communication with friends, family and health professionals.
Nutrition information.
Treatment evaluation information.

25. The Stanford Model: Impact
All studies looked at behavior, health status and utilization.
Findings included:
Improved self-efficacy
Reduced use of doctors, hospital emergency rooms
Improvements in health status - identified by BOTH the participant and the health provider
Ahn, S., Basu, R., Smith, M. L., Jiang, L., Lorig, K., Whitelaw, N., & Ory, M. G. (2013). The impact of chronic disease self-management programs: healthcare savings through a community-based intervention. BMC Public Health, 13,

26. Impact (continued)… Improved quality of life
Specific improvements in healthful behaviors
Improvement in overall health status
Decreased hospital stays: .49 days, per patient, over a two year time period
Decreased physician/emergency room use: fewer visits to the emergency room and to physicians, per patient, over a two year time period
Stanford University Patient Education Center,

27. Specific health-related impacts…
Increased physical activity
Cognitive symptom management
Improved communication with physicians
Better self-reported general health
Improved attitude
Less health distress
Less fatigue
Reduced disability
Fewer social/role limitations
Stanford University Patent Education Center; published articles (Lorig, K)

28. Train the Trainer Model
Group Leaders Facilitate community workshops for people with chronic diseases
Master Trainers In addition to what Leaders do, Master Trainers train Leaders
T-Trainers In addition to what Master Trainers do, T- Trainers train Master Trainers

29. Infrastructure Community networks Partnerships Financial support
Creating an effective chronic disease self-management system locally - Key Ingredients
Infrastructure
Community networks
Partnerships
Financial support
Sustained marketing
On-going recruitment
Challenges and Successes in Implementing the Chronic Disease Self-Management Program, National Council On Aging,

30. Community Health Worker Program
Dual certification as a CHW and a Stanford Chronic Disease Self Management Group Leader In collaboration with Friendly Inn Settlement House, Sisters of Charity Foundation and Fairhill Partners First Class started January, 2016

31. Stanford Programs Chronic Disease Self-Management Program (CDSMP)
 Tomando Control de su Salud (Tomando)
 Chronic Pain Self-Management Program (CPSMP)
 Cancer: Thriving and Surviving (CTS)
 Diabetes Self-Management Program (DSMP)
 Programa de Manejo Personal de la Diabetes (Manejo)
 Arthritis Self-Management Program (ASMP)
 Positive Self-Management (PSMP)
patienteducation.stanford.edu, October, 2015
There is a general chronic disease workshop and specific workshops on diabetes, HIV/AIDES, Arthritis, Pain, CHF
These programs are translated into many languages and offered worldwide.

32. Community Health Worker Role
Educational Advocacy Navigational Referral Clerical Community

33. Summary Chronic Disease Self-Management is:
Managing the work of dealing with a chronic disease and/or multiple disease conditions.
Managing the work of dealing with daily activities in light of debilitation and disability.
Managing emotional changes resulting from or exacerbated by the disease conditions.

34. Once a chronic disease is present, one cannot NOT manage, the only question is “how.”
Stanford University Patient Education Center, Lorig, 2003.

35. For further Information
Additional information & results of studies: Stanford University Patient Education Center,
Joan Thoman, PhD, RN, CNS, CDE
Pam Rutar, EdD, RN, CNE

36. Questions? ?