The emerging literature on chronic disease management suggests that successful programs rely on patient self management skills. Having been in the primary care role for 20 years, that initially seemed self evident and a bit “so what?” to me, thinking it meant that we just need to teach our patients a bit more in the primary care office.
However self-management skills refer to specific curricula of skills that can be taught to patients in formal programs, without doctors. Coordinating these activities with what goes on a primary care office, and the community, and other care-giving settings is critical. These specific skills involve patients setting their own goals, and then creating plans to reach those goals with the assistance of their primary care team and others, but not at the direction of their primary care team. This is a real mind shift for the primary care doctor also.
A doctor participating in the Vermont Blueprint (a statewide chronic disease management program) shared with me how difficult a shift in perspective this is. To enter an exam room for a patient with diabetes, and start by asking the patient what goals he or she has set, or how the patient is doing in accomplishing their own goals was a real shift from the doctor’s agenda. There will always be the need to compare the patient’s goals to evidence-based recommendations, but truly putting the patient in charge seems to have dramatic effect on the outcomes. Equipping them with methods for achieving their goals, including support groups, and behavioral health consultation availability in the primary care office are also important.
What are the benefits of successful patient self-management programs? People who participate in them increase exercise, manage their symptoms better, and report better health, reduced fatigue, and fewer limits on their activities. And they gain these benefits with fewer doctor visits and hospitalizations.
The Stanford model and the Coleman model feature these kinds of structured patient self-management skills. Southcentral Foundation, in Alaska, moves this patient-directed concept all the way to the governance of the health system, both centrally and in the communities they serve, by having the goals of the health system and the primary care network driven by Native American tribal leaders and the patients they serve. When chronic disease management becomes a part of the fabric of the community, with connections to prevention, and lifestyle modifications — including walking paths, group outings, school activities, and changes in nutrition — then real sustained change is accomplished. Examples of these successes are already in place.
This is a completely different approach from insurance company-based disease management programs of the last couple decades. Those “1 (800) dial a nurse” programs that were insurance-company specific, and not integrated with the primary care office, have left many primary care physicians with a negative impression of chronic disease management initiatives, because they did not work well. It is a very different approach to design and implement a program that is applied across an entire population, regardless of payer, and tightly integrate the provider network and across the continuum of care settings.
Mark Novotny is Chief Medical Officer of Cooley Dickinson Hospital in Northampton, MA.
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