|Self-Management Requires a Working Patient–Provider Partnership|
By Hayden Barry Bosworth, PhD
Professor of Medicine, Psychiatry, and Nursing, Duke University School of Medicine
Associate Director, Center for Health Services Research in Primary Care, Durham VAMC
Addressing the increased incidence of chronic disease is one of the most important challenges for health systems. In contrast to the traditional management of acute conditions, often characterized by a short period of patient adherence to following the doctor’s orders, management of a chronic disease requires that patients take a more active role in the day-to-day decisions about their illness.1 This disease paradigm requires a working patient–provider partnership that involves effective treatment within an integrated system of collaborative care, including self-management education and followup.2
Both the patient and the provider have important roles in the treatment of chronic conditions. Patients are expected to do what is needed to manage the condition on a daily basis while health care providers act as consultants, interpreters of symptoms, and resource persons, as well as offer treatment suggestions.3,4
Health care systems can support effective self-management by providing care that increases patient and family knowledge of the condition and their skills; increases provider’s knowledge of the patient’s needs and preferences; and supports the patient and family in the medical and psychosocial responses to the condition.
Three innovations on self-management in the AHRQ Health Care Innovations Exchange improved patient knowledge and/or patient health outcomes and reduced health care costs.
The Urban Health Plan Asthma Relief Street program in the Bronx, NY, takes an innovative comprehensive approach to treating asthma using standardized screening, guideline-based treatment, education, and self-management support. I was impressed with the community-based services they provide to high-risk, low-income people, including homeless individuals with a high prevalence of asthma. The program reduced hospitalizations among children with asthma and health care spending on adults and children with asthma, according to a small study.
It would be good to know the costs of implementing the program because the more data available that supports self-management, the easier it is to persuade others to invest in it. Also, I would like to know how they developed the community partnerships and the alternatives to an electronic medical record system to monitor patients’ quality of care and institutionalize changes.
The primary care clinic innovation developed by Wake Forest Baptist Health and Wake Forest University School of Medicine in Winston-Salem, NC, enables low-literacy patients to increase their knowledge and self-management by viewing a video related to their condition (asthma or diabetes), medication (anticoagulant), or screening (colon cancer screening), and general office information during their primary care visit. The 3- to 5-minute videos are viewed on tablet computers (iPads) before or after patients see their physician. The results showed that patient’s knowledge of asthma and anticoagulation management improved after viewing those videos. Although it’s important to target health literacy, the videos shouldn’t replace direct provider–patient communication, including closing the loop after the patient views the video. Instead of physicians, nurses or other medical personnel (such as pharmacists) could be trained to provide self-management, which should also cover goal setting and understanding the patient and families’ needs.
The HealthyHeartClub.com program by CreativePharmacist.com in Evans, GA, uses pharmacists to educate patients with heart disease or at risk of developing heart disease about setting health goals and adopting healthy behaviors, including diet, exercise, and medication adherence. After the initial visit, the patient checks in with the pharmacist via e-mail, uses the Website for information and tracking progress, and participates in monthly group classes. While the monthly fees for participants ($20 to $30 per person) are fairly low, not everyone can afford them, which limits access. In a primary care model, where physicians prescribe and manage medications, nurses could do the education and coaching, which would be less expensive than using a pharmacist. Also, the program relies on patients to coordinate their care between the pharmacists and their primary care providers by providing patients an enrollment letter and encouraging them to print Web site progress reports for their primary care doctors. Another option would be to electronically send this information to primary care providers directly from the Web site or enable providers to have access to this information on the Web site. Finally, I look forward to the results of the formal evaluation in 2012 and the associated costs because the preliminary data look promising.
Self-management programs that can be adapted to primary care medical homes and tailored to the prevention of chronic disease will be in demand in the near future as health care spending on prevention increases and federal reimbursement policies support reducing hospital readmissions and primary care medical homes.
1Anderson RM, Funnell MM. Patient empowerment: myths and misconceptions. Patient Educ Couns. 2010;79(3):277-82. [PubMed]
2Bodenheimer T, Lorig K, Holman H, et al. Patient self-management of chronic disease in primary care. JAMA. 2002;288(19):2469-75. [PubMed]
3Azarmina P, Prestwich G, Rosenquist J, et al. Transferring disease management and health promotion programs to other countries: critical success factors. Health Promot Int. 2008;23(4):372-9. [PubMed]
4Lorig K. Self-management education: more than a nice extra. Med Care. 2003;41(6):699-701. [PubMed]
Disclosure Statement: Dr. Bosworth has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.
Original publication: June 08, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: June 05, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: May 21, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.