1. Chronic Disease Self-Management
A Patient-Centered Option for Managing the Healthcare Challenge
Presentation prepared by:
John Irwin,
Healthcare & Community Informatics Consultant,
Stanford Licensed Chronic Disease Self-management Program Master Trainer

2. Today you will hear…
An introduction to chronic disease self-management
A closer look at one evidence-based self-management 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…
Sources: NGA study; 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%
Sources : Partnership for Solutions: Better Lives for People with Chronic Conditions, WA State ; Health Affairs, 2005; 24 (1) 80-92; Center for Healthy Aging (NCOA)

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
Sources: Stanford University (Lorig, K.); Center on an Aging Society, National Institute on Aging

6. Self-Management Definition
“Involves [the person with the chronic disease] engaging in activities that protect and promote health, monitoring and managing of symptoms and signs of illness, managing the impacts of illness on functioning, emotions and interpersonal relationships and adhering to treatment regimes.”
Self Management involves a partnership between individuals and their health workers. In this relationship
the individual has some responsibilities. They include:
engaging in activities which promote their health.
monitoring and managing their symptoms day-to-day
adhering to treatments that have been agreed to with health workers.
When the individual has mastered these skills, they are said to be good self managers.
Source: Center for Advancement in Health (1996). Indexed bibliography on Self-management for People with Chronic Disease. Washington DC.. Page 1

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, Action Plans)
A chronic disease may never be cured. We are looking to improve quality of life.

9. 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’.

10. Patients Increasingly Want to Retain Independence
More people with chronic disease believe…
They have a “right” to take part.
They are capable of taking part, with the right supports.
Patient assertiveness is necessary…and needed.
Source: California Healthcare Foundation

11. 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.
Source: Lorig and Holeman 2003
Point 1
“If life were fair, we'd each be limited to a single major health problem…But it isn't.
Diseases, like wolves, tend to travel in packs.”
Harvard Heart Letter, 01-JUL-03

12. 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.
Sources: Stanford University Patient Education Center; Center for Healthy Aging (NCOA)

13. Self-Management Skills
Problem-solving
Decision-making
Resource Utilization
Formation of a patient- provider partnership
Action-planning
Self-tailoring
Source: Lorig and Holeman 2003

14. 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.

15. 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

16. Stanford’s CDSMP is Evidence-based
Found to truly benefit targeted populations.
Demonstrated it does not cause harm.
Demonstrated it does not waste resources.
Reference:

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

18. 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

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

20. 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.

21. 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.

22. 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
Sources: Stanford University Patient Education Center; Society of Behavioral Medicine publication (2003)

23. 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
Source: Stanford University Patient Education Center; Center for Healthy

24. 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
Sources: Stanford University Patent Education Center; published articles (Lorig, K)

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

26. Reasons to support this approach…
Disease and demographic challenges will be unrelenting - “We need to start yesterday…”
Limited availability of reliable, evidence-based (proven) approaches to chronic disease self-management
Better utilization of current resources necessary; more efficient use of physician time desired
Sources: Society of Behavioral Medicine publication (Lorig K., Holman, H.)

27. 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.

28. Once a chronic disease is present, one cannot NOT manage, the only question is “how.”
(Bateson 1980, Lorig, 2003)

29. For further information…
Contact:
John Irwin
Health & Community Informatics Consulting
(541) Or
Sharon Johnson
Oregon State University
(541) x210
Additional information & results of studies: