Supporting self-management of chronic health conditions: Common approaches

Abstract

Objective

The aims of this paper are to provide a description of the principles of chronic condition self-management, common approaches to support currently used in Australian health services, and benefits and challenges associated with using these approaches.

Methods

We examined literature in this field in Australia and drew also from our own practice experience of implementing these approaches and providing education and training to primary health care professionals and organizations in the field.

Results

Using common examples of programs, advantages and disadvantages of peer-led groups (Stanford Courses), care planning (The Flinders Program), a brief primary care approach (the 5As), motivational interviewing and health coaching are explored.

Conclusions

There are a number of common approaches used to enhance self-management. No one approach is superior to other approaches; in fact, they are often complimentary.

Practice implications

The nature and context for patients’ contact with services, and patients’ specific needs and preferences are what must be considered when deciding on the most appropriate support mode to effectively engage patients and promote self-management. Choice of approach will also be determined by organizational factors and service structures. Whatever self-management support approaches used, of importance is how health services work together to provide support.

Introduction

Health professionals can enhance health outcomes for patients with chronic conditions by working collaboratively with their patients to address perceived power differences and enhance respect for the expertise that both patients and health professionals bring to the interaction. A number of approaches are currently available to assist health professionals to provide chronic condition self-management support to patients in this growing area of focus and need. The aims of this paper are to: (i) discuss differences between acute and chronic conditions relevant for the purpose of enhancing chronic condition management within health service systems; (ii) provide some details on the principles of self-management; (iii) describe common modes of support using the examples of the Stanford and Flinders approaches to self-management support as well as the 5As Model, motivational interviewing and health coaching, and the benefits and challenges associated with using them; and (iv) discuss how health professionals can enhance their support and improve patients’ program engagement and adherence generally.

The term chronic condition encompasses disability and disease conditions that people may ‘live with’ over extended periods of time (i.e. more than 6 months). Chronic condition self-management is amenable to generic approaches based on the understanding that there are generic self-management tasks regardless of diagnosis. Chronic disease is a subset of chronic conditions and refers to a specific medical diagnosis. It may be more likely to have a progressively deteriorating path than other chronic conditions [1].

Prevention and management of chronic conditions is becoming increasingly important as improvements in health status lead to greater proportions of the population in many countries entering older age. This has been compounded by lifestyle issues brought about by, for example, improved standards of living and consequent changes in diet and activity levels. These changes have led to increasing financial pressures on healthcare systems to cope with the increased demand for health services [2], [3]. An important challenge that health professionals face is that patients, as a reflection of us all, generally do not immediately feel the consequences of poor lifestyle choices on their health and wellbeing. A vast range of psychosocial issues (including poverty, literacy, domestic violence, and community access and resources) can determine how people respond to this challenge. Knowing what to do and feeling empowered to take action are vastly different phenomena. Multi-morbidity is common and is not well managed within existing health systems [4]. Within this context, patient's day-to-day responses to, and ownership of, the challenge of addressing their health becomes increasingly relevant.

Health systems internationally have traditionally worked according to an acute model of care where health professional ownership of solutions is paramount and the patient is a passive recipient of their expert advice. This works well for acute conditions which are generally associated with short episodes of illness and there are a number of assumptions about the illness and the roles of health professionals and patients. Also, adherence to medications and treatment regimes is often less problematic because patients are likely to be prepared to stick to a prescribed regimen for a short period of time for the purpose of getting better. However, on the other side of the spectrum are the chronic conditions. They involve a quite different set of assumptions, roles and realities for the patient as the expert with implications for the health professional's role [5]. Bodenheimer et al. [6] remind us that people with chronic conditions are the principal care-givers. Health care professionals should be consultants supporting them in this role. “Each day, patients decide what they are going to eat, whether they will exercise and to what extent they will consume prescribed medicines.” (p. 2470). People with chronic conditions and their families have many accommodations, choices and decisions to make about how they will manage their overall health and wellbeing and how they will adhere to health professional advice, not solely based on ‘knowing what is good for them’, and often with long-term consequences for themselves and others [7]. Effectiveness of health service support depends on health professionals who understand this complexity as part of ongoing support services. Further to this interpersonal complexity is the health system's challenge of attempting to shift from an acute focus to a chronic care focus given that chronic conditions are expected to consume approximately 80% of healthcare costs by 2020 [2]. This requires system and cultural change, which is often hard (see Table 1 for further details).

Chronic condition management and self-management support requires not merely health professional skills in person-centered care and supporting patients’ behavior change. An organizational and system-wide approach that looks at the psychosocial, economic and political context in which services are delivered is needed [9]. The magnitude of health burden on individuals, communities and systems also requires a population health approach that fully acknowledges the social determinants of health [1], [10].

Chronic condition self-management is what patients do and includes a broad set of attitudes, behaviors and skills that they direct towards managing the impact of the chronic condition(s) on their lives. It includes, but is not limited to self-care and it may also encompass prevention. The following are believed to contribute to this process [2]:

• Having knowledge of the condition and/or its management;

• Adopting a self-management care plan agreed and negotiated in partnership with health professionals, significant others, carers and other supporters;

• Actively sharing in decision-making with health professionals, significant others and/or carers and other supporters;

• Monitoring and managing signs and symptoms of the condition;

• Managing the impact of the condition on physical, emotional, occupational and social functioning;

• Adopting lifestyles that address risk factors and promote health by focusing on prevention and early intervention; and

• Having access to, and confidence in the ability to use support services.

Chronic condition self-management support is what health professionals, carers and the health system do to assist the person to manage their chronic condition(s) [2].

The capacity to self-manage can be influenced by the illness itself and factors such as patients’ individual attributes, and social and cultural factors. Lorig and Holman [11] discriminate five core-self-management skills. These are: (i) problem solving; (ii) decision-making; (iii) resource utilization; (iv) forming a patient/health care provider partnership; and (v) taking action. Health professionals’ attitudes and behaviors have also been shown to influence patients’ capacity to self-manage. The ability to self-manage needs to be assessed before intervention is instigated since it will influence the choice of self-management support to be used. Whereas some patients require minimal self-management support, others with complex and co-morbid conditions often benefit from more intensive support. Effective learning methods range from group to individual intervention with some benefiting from additional counseling intervention. Such methods can be used either individually or together as part of an overall suite of supports. The challenge for health professionals is to understand which methods are best suited to support which patients in which contexts. This paper aims to help address this challenge, particularly for health professionals who may be unfamiliar with chronic condition self-management support approaches.