Improving the Outcomes of Chronic Diseases
Through Self-Management Education
by Laura E. Santurri
Chapter Table of Contents
II. Defining Patient Empowerment
III. Defining Two Prevalent Chronic Diseases – Diabetes and Hypertension
IV. Defining Self-Management Education
V. Self-Management Education and Self-Efficacy
VI. Integrating Self-Management Education into
VII. Other Sources of Information
Until the middle
of the last century, acute diseases dominated the
One way that health
professionals have sought to improve health outcomes is through patient
empowerment. This chapter will begin
with a brief introduction to the concept of patient empowerment and will
discuss self-management education as one way that patient empowerment can be
encouraged. The chapter will end with a
discussion of how self-management education has been integrated, and could
further be integrated, into the
Defining Patient Empowerment
The concept of patient empowerment is discussed frequently in medical literature, especially surrounding the topic of chronic disease and its management. Typically, patient empowerment is defined as an individual being an active member of his/her disease management team. For example, a patient that is empowered would be able to make decisions regarding his/her treatment with the respect of the health professionals that are treating the disease.4 This idea has also been expressed in discussions of patient-centeredness in medicine – that treatments should be aimed at what the patient perceives to be the problematic symptoms.5 Of course, the power of the patient to choose what treatments he/she wishes to receive presupposes that the patient has the ability to be a patient at all, meaning that he/she has access to healthcare. This is not always the case, so to take a step back, it might seem that access is the first step to patient empowerment and choice is second to that.
Patient empowerment does not just encompass the ability of the patient to make decisions and be active in their care, it also encompasses their education on the topic. Typical patient education generally focuses on imparting knowledge to the patient that is disease-specific,6 and this is certainly important. However, patient empowerment also means that the patient is educated in making good decisions about their health and not just the “medical” decisions. It also means that they are educated in managing how the disease affects their roles in life (such as parent, teacher, spouse, etc.) as well as the emotional impact of the disease. It could be said that true patient empowerment integrates multiple concepts that allow a patient to effectively self-manage their disease.5
Defining Two Prevalent Chronic Diseases – Diabetes and Hypertension
Diabetes and hypertension are two prevalent diseases in the U.S., with diabetes affecting 20.8 million Americans (or 7% of the population)7 and hypertension affecting 50 million Americans (or 1 in 5 adults).8 Because these diseases are prevalent in the U.S., they will be used to provide examples of how one particular self-management program, the Chronic Disease Self-Management Program, can be applied. Therefore, they will be defined here so that the reader can have a better understanding of how they are used as examples later in the chapter. It is also worth noting that self-management education is also highly applicable to other chronic diseases, such as asthma, arthritis, and depression, and even lifestyle management in general.
Type II diabetes is the most common form in
Treatment of type II diabetes can include lifestyle adjustments, such as diet modification (reducing carbohydrate intake) and increasing levels of physical activity as well as different oral medications or insulin injections. Most importantly, a diabetic’s blood sugar levels should be monitored regularly to avoid diabetic complications, such as eye, kidney, and nerve disease, dental problems, and hyperglycemia.9
Hypertension, also commonly referred to as high blood pressure, is characterized by blood pushing against blood vessel walls with too much force. This increased pressure results in the heart being overworked in its attempt to pump blood through the body. There are two stages of hypertension. Stage 1 is defined as having a blood pressure of 140-159/90-99, and stage 2 is defined as having a blood pressure of 160 and above/100 and above. Having hypertension does not always mean that an individual will have obvious symptoms (as nearly 1/3 of the individuals with the disease do not know they have it), but some of the more common symptoms include headache, fatigue, chest pain, irregular heartbeat, blood in the urine, and difficulty breathing.10
Just as with diabetes, treatment for hypertension can include lifestyle adjustments, such as lowering sodium intake, losing weight, quitting smoking, and increasing physical activity. Oral medications, such as ACE inhibitors and beta-blockers, are also available and used to treat the disease. However, just as monitoring blood sugar is vital for the diabetic patient, monitoring blood pressure is also important for the individual with hypertension.10
Defining Self-Management Education
According to Dr. Kate Lorig, a leader in the field of chronic disease management, every patient with a chronic disease is involved in self-management, whether or not it is effective in improving quality of life. Stated simply, “one cannot not manage.”6 However, Lorig defines self-management education as, “learning and practicing the skills necessary to carry on an active and emotionally satisfying life in the face of a chronic condition.”11 One notices immediately how the definition of self-management education sounds quite a bit like the definition of patient empowerment.
was with these definitions in mind that Dr. Kate Lorig and the
Key Concepts of the CDSMP
the beginning of Dr. Lorig’s work at the
In future research studies that tested this hypothesis, it was found that both baseline self-efficacy and changes in self-efficacy scores were significantly associated with improvements in health status.12,22 Given this, and the fact that many other studies have shown associations between self-efficacy and health status,23 the four important ingredients of self-efficacy enhancement were permanently integrated into the CDSMP. The four important ingredients are performance mastery or creating action plans, modeling (i.e. having peers who practice effective self-management teach the course), interpretation of symptoms (i.e. understanding that symptoms can have multiple causes), and social persuasion (i.e. surrounding oneself with those who are practicing effective self-management).6 It should be noted that modeling and social persuasion are often accomplished by having the patient attend support group meetings that are culturally competent and attended by individuals in similar situations.
Integrating Self-Management Education Into Our Healthcare System
the fact that the CDSMP has demonstrated effectiveness in improving outcomes
and costs associated with chronic illness, it seems that the next logical step
would be integrating it, and programs like it, into the standards of medical
care for individuals with chronic disease in the
Preparing the Patients
In the 20th century, public expectations for medical care shifted from individuals, families, and communities to healthcare systems and institutions. With this shift in expectation, patients are now accustomed to looking to those healthcare providers and institutions for disease prevention, treatment, and cure. This means that personal responsibility for the management of disease is not usually on the individual or his/her family and community. If self-management education is to be presented as an acceptable option to today’s patients, social marketing campaigns will be needed, physicians will need to actively refer patients (and express to their patients why self-management is important), and options for access to self-management education will need to be offered (such as through group sessions, telephone counseling, and Internet-delivered programs).6
Securing a Financial Commitment from the Insurance Industry
Even with the needed “buy-in” from both healthcare professionals and patients, self-management education cannot be integrated without adequate financing. Currently, little funding exists from government insurance providers, such as the Centers for Medicare and Medicaid Services, the U.S. Department of Veteran Affairs, or state Medicaid programs. This lack of coverage is generally due to the difficult time that providers and payers have in identifying effective programs that are applicable to large populations of people. However, programs such as the CDSMP, once shown to meet the standards of effectiveness, should be fully funded just as any other treatment or medication would. If the program truly is effective in increasing health-related quality of life and decreasing healthcare utilization, this would most likely mean that the insurance companies would not be billed for as many doctor’s visits or healthcare services.
Effectiveness should not be the only reason for insurance companies to provide coverage for this program, as there are other financial incentives built into the very structure of the program. First of all, the program is offered in a group setting, which costs less than individual or one-on-one care, and it is also offered by lay individuals and not necessarily health professionals, which means that the insurance companies would not be billed for any extra doctor time. In other words, patients can receive the same important message that could technically be provided by the physician in the context of a healthcare visit, but in a more cost-efficient setting. The other major benefit to this program is that long-term results have been shown. It would seem extremely beneficial for insurance companies to offer this service, which has clear boundaries (6 sessions total) and can offer long-term benefit well beyond those boundaries.
It is also worth noting that Health Savings Accounts (HSA’s) (fed by tax-deferred money from an individual’s paycheck) could also provide another avenue for coverage for these types of patient programs, if the patients themselves deem it a worthwhile expenditure.
CDSMP and other types of self-management education may have an important place
Other Sources of Information
For readers who
wish to explore the topic further, visit the