Chronic Disease Self-Management Program

Self-management refers to the activities and behaviors an individual undertakes to control and treat a chronic condition. The goal of self-management programs is to improve physical and emotional health and quality of life and minimize disease-related impairments.

Self-management programs are based in self-efficacy, or a patient's belief in their ability to accomplish a behavior. This is theorized to lead to improved health outcomes. Programs deliver health education to teach self-management skills and other strategies that emphasize the patient's role in actively managing their chronic disease and support behavior change.

For examples, education and skills that are typically addressed in diabetes self-management programs include:

Testing blood sugar (glucose)
Consuming balanced meals and appropriate portion sizes
Engaging in regular exercise
Drinking water and avoiding dehydration
Taking and adjusting medications as prescribed
Conducting self-foot checks
Monitoring other signs or symptoms caused by diabetes

The Chronic Disease Self-Management Program

The Chronic Disease Self-Management Program (CDSMP) from the Self-Management Resource Center (SMRC) is an evidence-based chronic disease self-management program. CDSMP is designed to increase self-efficacy among participants and improve the skills required to manage chronic conditions regardless of specific diagnosis.

CDSMP helps participants master six fundamental self-management tasks:

Solving problems
Making decisions
Utilizing resources
Forming a patient-provider partnership
Making action plans for health behavior change
Self-tailoring

The CDSMP was originally designed as a six-week small-group in-person workshop and has been adapted in numerous ways. Some of the formats available include virtual meeting groups, an asynchronous or self-paced online version, and mailed toolkits with or without phone check-ins. The CDSMP can also be delivered using telehealth, which can make the program more accessible for rural residents. It is available in English, Spanish, and other languages.

In addition, the SMRC CDSMP has been adapted for various chronic conditions, including for diabetes by building upon the Stanford Diabetes Self-Management Program. The National Council on Aging (NCOA) offers an extensive list of evidence-based CDSMPs.

Action Plans

Self-management is particularly effective when patients develop action plans outlining the steps they will take to implement self-management strategies. Action plans can be written or oral, based on standard templates or tailored to each patient. The action plan drives patients to move beyond knowledge of their self-management responsibilities and pushes them to think about how they will effectively change their behavior. A 2016 systematic review suggests that the development of chronic obstructive pulmonary disease (COPD) action plans is associated with reduced hospitalizations and emergency department visits, compared to usual care. Action plans can provide enhanced benefits when supplemented by a short educational follow-up that supports patient plan adherence.

Rural Chronic Disease Self-Management Program Examples

Bassett Healthcare Network in Cooperstown, NY, offers a variety of “Living Well” programs for chronic conditions, including specialized programs for chronic pain, diabetes, and cancer. The programs deliver six-to-seven-week workshops in a variety of formats suitable for rural residents. Participants are taught self-management techniques to help them address the challenges of managing their chronic condition.
The Northwest Regional Council in Washington State offers Wisdom Warriors, a CDSMP program adapted for Native American/Alaskan Natives including the promotion of traditional foods, cultural activities, and healthy traditions. NCOA provides more information on adapting CDSM programs for tribal communities.
The University of Virginia Diabetes Tele-Education Program offers diabetes education courses that teach diabetes self-management skills. The program is delivered through video conferencing technology and made available to people who have, or are at high risk for developing, diabetes.
The Rural Health Network of South Central New York provides community health education programs including the seven-week Living Health and the Chronic Pain Self-Management Program. The program focuses on providing peer support and developing communication skills to better manage these conditions.
The Meadows Diabetes Education Program offers the Association of Diabetes Care & Education Specialists (ADCES) credentialed Diabetes Self-Management Education classes, as well as the CDC's National Diabetes Prevention Program to community members in rural Georgia. The program helps patients learn effective diabetes self-management practices. Sessions are free and open to all interested community members. The program also uses telehealth to promote care coordination between local clinics and specialists. Overall, the program has demonstrated a reduction in emergency department use and a decrease of inpatient hospitalizations.
The Sarah Bush Lincoln Health Center in rural east central Illinois uses evidence-based programming to reduce hospitalizations and improve the quality of life among COPD patients. The program focuses on patient empowerment, self-management behaviors, and medication management. The program uses motivational interviewing as a technique to assist patients with improving self-management skills.
Bridges to Care Transitions, a collaborative program led by Bay Rivers Telehealth Alliance, offers remote home monitoring and chronic disease management coaching to patients with chronic illnesses in rural Tidewater, Virginia. Patients enroll in the program at the time of discharge from the hospital and participate in up to 90 days of remote home monitoring and coaching. The program incorporates a variety of evidence-based models, including the Coleman Care Transitions model, the Healthy IDEAS model, and the Stanford model.
The National Kidney Foundation offers the Take Charge of Your Kidney Health program, a free, 8-week virtual program for people living with chronic kidney disease. Participants learn how to manage illness and improve quality of life through self-management techniques and tools, medication management, and nutrition.
There are multiple rural programs for arthritis self-management in several states including Oregon, Missouri, and North Dakota. Many of these programs incorporate physical activity and CDSM education.
Wellness programs, which promote healthy habits, can help disease management practices, increase physical activities, and encourage healthy eating. Some of these programs include: Fit & Strong!® and the StrongPeople™ Program.

Implementation Considerations

Strong patient-provider relationships and clear communication are critical to successful chronic disease self-management programs. Care teams can support and encourage patient self-management, build confidence, and hold patients accountable. Further, having CDSMP instructors who are trusted providers or community members can help with enrollment and retention in the program.

Strong partnerships with healthcare providers, caregivers, and loved ones also underpin effective self-management programs. These individuals can offer emotional support, model healthy behaviors, participate in exercise activities, and facilitate communication around effective self-management practices.

In addition, organizations looking to implement CDSMP programs should consider the intended audience, health-related social needs, and other factors that might encourage or be a barrier to participation. For example, when conducting CDSMP workshops in person, programs can consider finding ways to help participants with transportation or hold the sessions in community centers or other easily accessible locations. Hosting workshops at a variety of times that work for different participants can also be helpful, such as early evening hours for a working population. Programs interested in implementing CDSMP in their communities should also consider the resources needed, including training, licensing, and potential fees.

Program Clearinghouse Examples

Resources to Learn More

COPD Action Plan & Management Tools
Website
Offers a variety of resources and tools for managing COPD. Includes information on nutrition, physical activity, managing daily activities, and an action plan template in English and Spanish for patients to complete with their healthcare provider.
Organization(s): American Lung Association

Dissemination of Chronic Disease Self-Management Education (CDSME) Programs in the United States: Intervention Delivery by Rurality
Document
Describes a study to determine the geospatial distribution of CDSME programs in the U.S. by reviewing 2009 to 2016 data from 83 grantees across 47 states to compare dissemination characteristics by location. Highlights the traditional role of organizations within the aging services network and the need for increased partnerships, marketing, communication among stakeholders, and technical assistance to facilitate CDSME program growth in rural areas.
Author(s): Smith, M.L., Towne, S.D., Herrera-Venson, A., et al.
Citation: International Journal of Environmental Research and Public Health, 14(6), 638
Date: 6/2017

Offering Chronic Disease Self-Management Education in Rural Areas
Document
Provides recommendations and resources for implementing chronic disease self-management education (CDSME) programs in rural settings. Includes success stories and innovative approaches focused on rural CDSME programs.
Organization(s): National Council on Aging
Date: 7/2015

Qualitative Exploration of Rural Focus Group Members' Participation in the Chronic Disease Self-Management Program, USA
Document
Examines the benefits of participation in a six-week chronic disease self-management program (CDSMP) as perceived by rural residents experiencing chronic disease. Study focused on the extent of positive behavioral change and improved health of rural populations.
Author(s): Harvey, I.S., Janke, M.
Citation: Rural and Remote Health, 14(4)
Date: 10/2014