Chronic Disease Self Management Program

Developed by Stanford University

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The Chronic Disease Self-Management Program is a workshop given for two and a half hours, once a week, for six weeks, in community settings such as senior centers, churches, libraries, clinics, and hospitals. The program was developed  for people with chronic health problems and their significant others. People with different problems attend the same workshop together. Workshops are facilitated by two trained leaders, one or both of whom are non-health professionals with at least one chronic condition.

Subjects covered include:
  • techniques to deal with problems such as frustration, fatigue, pain, and isolation
  • appropriate use of medications
  • communicating effectively with family, friends, and health care professionals
  • appropriate exercise for maintaining and improving strength, flexibility, and endurance
  • the importance of good nutrition, and guidance with food choices
  • Mutual support and encouragement to help you improve your quality of life
There is also great emphasis on three process skills, action planning, disease related problem solving, and decision making.
The Self-Management Program will not conflict with existing programs or treatment. It is designed to enhance regular treatment and disease-specific education such as Better Breathers,cardiac rehabilitation, or diabetes instruction. In addition, many people have more than one chronic condition. The program is especially helpful for these people, as it gives them the skills to coordinate all the things needed to manage their health, as well as to help them keep active in their lives.
The Division of Family and Community Medicine in the School of Medicine at Stanford University received a five year research grant from the federal Agency for Health Care Research and Policy and the State of California Tobacco-Related Diseases office. The purpose of the research was to develop and evaluate, through a randomized controlled trial, a community-based self-management program that assists people with chronic illness. The study was completed in 1996. The content of the program was developed from holding focus groups with potential participants as well as having National and International experts (RDs, MDs, PTs, OTs, RNs and diabetes educators) assist in developing key messages and being sure that the content was accurate, and evidenced based. The process of the program was based on the experience of the investigators and others with self-efficacy, the confidence one has that he or she can master a new skill or affect one’s own health. The content of the workshop was the result of focus groups with people with chronic disease, in which the participants discussed which content areas were the most important for them.
Over 1,000 people with heart disease, lung disease, stroke or arthritis participated in a randomized, controlled test of the Program, and were followed for up to three years. The developers looked for changes in many areas: health status (disability, social/role limitations, pain and physical discomfort, energy/fatigue, shortness of breath, psychological well-being/distress, depression, health distress, self-rated general health), health care utilization (visits to physicians, visits to emergency department, hospital stays, and nights in hospital), self-efficacy (confidence to perform self-management behaviors, confidence to manage disease in general, confidence to achieve outcomes), and self-management behaviors (exercise, cognitive symptom management, mental stress management/relaxation, use of community resources, communication with physician, and advance directives). You can find references to the studies and those of others on the following website, http://patienteducation.stanford.edu.
Subjects who took the Program, when compared to those who did not, demonstrated significant improvements in exercise, cognitive symptom management, communication with physicians, self-reported general health, health distress, fatigue, disability, and social/role activities limitations. They also spent fewer days in the hospital, and there was also a trend toward fewer outpatient visits and hospitalizations. These data yield a cost to savings ratio of approximately 1:10. Many of these results persisted for as long as three years.
In 2008 The Centers for Disease Control & Prevention (CDC) in partnership with the National Council on Aging on the issue of financial sustainability for evidence-based health programs for older adults reviewed CDSMP studies. The authors, Catherine Gordon, RN, MBA a Senior Public Health Analyst in the Office of the Director, and Tracy Galloway, MPH, a Public Health Analyst in the National Center for Health Marketing at CDC made the following statement in their report.

There is evidence that CDSMP results in reductions in healthcare expenditures. There is a range in the amount of money saved and the healthcare settings in which these cost savings/utilization decreases occurred, but the research points to moderate expenditure reductions. The statement “CDSMP results in reductions in healthcare expenditures” is made with a reasonably high degree of confidence. This finding is consistent with the available evidence, but is limited by the fact that measurement approaches differ across studies and utilization decreases are not uniform. In four studies there were fewer emergency room (ER)visits, in three studies there were fewer hospitalizations, and in four studies there were fewer days in the hospital. In two studies there were reductions in outpatient visits. All of the preceding studies were able to demonstrate statistical significance. We found no studies in which costs were increased.

There is evidence to support the notion that CDSMP saves enough money in healthcare expenditures within the first year to pay for the program. This statement is made with a moderate degree of confidence. This degree of confidence reflects the range of cost estimates used for CDSMP and that there is no common cost accounting used to calculate program costs.

The available evidence also suggests that CDSMP results in more appropriate utilization of healthcare resources, addressing healthcare needs in outpatient settings rather than ER visits and hospitalizations. While CDSMP is not a cost-cutting strategy in and of it, it almost certainly results in improved health-related outcomes and reduced healthcare utilization sufficient to render the program cost neutral. Further work will be needed to more precisely calculate the CDSMP return on investment, using uniform cost methodologies and utilization metrics.
Leaders are trained in groups of from 10 to 25 over 4 days by certified Master Trainers. Every effort is made to recruit at least 10 people, small trainings do not give a good opportunity for modeling and really learning how the workshop “feels". During the four days the Leader Trainees experience every activity in the workshop’s six sessions, set and report success on their own action plans, practice teach two activities with a co-leader, and practice handling difficult people in groups. The practice teaches are an especially important part of training. They serve to give the participants practice with the program and to gain confidence in delivering the program.

Because most people coming to the training usually have one or more chronic conditions, the trainings are limited to six hours per day. The Health Initiative provides two six-hour training days on two consecutive weeks. To become a leader someone must attend ALL of the training. If someone really has to miss a half day of training the Master Trainers will make every effort to schedule an individual make-up session.
 

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