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Collaborative Management of Chronic Illness
Abstract
In chronic illness, day-to-day care responsibilities fall most heavily on patients and their families. Effective collaborative relationships with health care providers can help patients and families better handle self-care tasks. Collaborative management is care that strengthens and supports self-care in chronic illness while assuring that effective medical, preventive, and health maintenance interventions take place. In this paper, the following essential elements of collaborative management developed in light of behavioral principles and empirical evidence about effective care in chronic illness are discussed: 1) collaborative definition of problems, in which patient-defined problems are identified along with medical problems diagnosed by physicians; 2) targeting, goal setting, and planning, in which patients and providers focus on a specific problem, set realistic objectives, and develop an action plan for attaining those objectives in the context of patient preferences and readiness; 3) creation of a continuum of self-management training and support services, in which patients have access to services that teach skills needed to carry out medical regimens, guide health behavior changes, and provide emotional support; and 4) active and sustained follow-up, in which patients are contacted at specified intervals to monitor health status, identify potential complications, and check and reinforce progress in implementing the care plan. These elements make up a common core of services for chronic illness care that need not be reinvented for each disease.
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“There is a growing body of evidence that shows supporting people to self-manage their health and care can lead to improvements in clinical and humanistic outcomes [12–18], reducing the economic impact of chronic disease and a means of contributing to the sustainability of the global healthcare system.”
From Helping patients help themselves: A systematic review of self-management support strategies in primary health care practice (2019) · cites this paper as [13]
In the citing paper
“Similar trends have been found in existing literature in several contexts that self-management is essential to optimizing clinical and humanistic outcomes for patients with chronic conditions [13, 15, 18, 152–155].”
From Helping patients help themselves: A systematic review of self-management support strategies in primary health care practice (2019) · cites this paper as [13]
In the citing paper
“For effective medical care of chronic illness, such as Type 2 diabetes mellitus (T2DM), adequate and sustainable self-management initiated by patients is important [1-3].”
From Long-Term Engagement With a Mobile Self-Management System for People With Type 2 Diabetes (2013) · cites this paper as [1]
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“…clinicians for the more severely ill and taking advantage of multidisciplinary care teams that include highly skilled nurses and other health professionals (Katon, Von Korff, Lin, & Simon, 2001; Pincus, Hough, Houtsinger, Rollman, & Frank, 2003; Von Korff, Gruman, Schaefer, Curry, & Wagner, 1997).”
BackgroundPiette, J. D., Mendoza-Avelares, M. O., Milton, E. C., Lange, I., & Fajardo, R. (2010) · Telemedicine and e-Health · doi:10.1089/tmj.2010.0074 · Cited by 45
Improving adherence to a cholesterol-lowering diet: a behavioral intervention study
Burke, L. E., Dunbar-Jacob, J., Orchard, T. J., & Sereika, S. M. (2005) · Patient Education and Counseling · doi:10.1016/j.pec.2004.05.007 · Cited by 46
Bagnasco, A., Giacomo, P. D., Mora, R. D. R. D., Catania, G., Turci, C., Rocco, G., & Sasso, L. (2013) · Journal of Advanced Nursing · doi:10.1111/jan.12178 · Cited by 55
“Education and support for self-management are fundamental when caring for people with a chronic disease like diabetes, according to the Chronic Care Model (Wagner et al.1996a, b, Von Korff et al.1997), which introduced a particular way of viewing patients (Bodenheimer et al.2002a,b).”
BackgroundMind and Body Reunited: Improving Care at the Behavioral and Primary Healthcare Interface
Mauer, B. J., & Druss, B. G. (2009) · The Journal of Behavioral Health Services & Research · doi:10.1007/s11414-009-9176-0 · Cited by 48
Food insecurity among veterans: Findings from the health and retirement study
Brostow, D. P., Gunzburger, E. C., & Thomas, K. S. (2017) · The journal of nutrition health & aging · doi:10.1007/s12603-017-0910-7 · Cited by 46
Clinical aspects of adherence to pharmacotherapy in Parkinson disease
Straka, I., Minár, M., Gažová, A., Valkovič, P., & Kyselovič, J. (2018) · Medicine · doi:10.1097/md.0000000000010962 · Cited by 47
“Patient’s knowledge about disease Grosset([9]); Leopold et al([10]); Okuno et al([15]); von Korff et al([19]); Valldeoriola et al([5])”
BackgroundVinter-Repalust, N., Petriček, G., & Katić, M. (2004) · PubMed · Cited by 46
Chronic illness as a family process: A social‐developmental approach to promoting resilience
Shapiro, E. R. (2002) · Journal of Clinical Psychology · doi:10.1002/jclp.10085 · Cited by 46
The Care of Older Women With Early-Stage Breast Cancer
Silliman, R. A., Demissie, S., & Troyan, S. L. (1999) · Medical Care · doi:10.1097/00005650-199910000-00009 · Cited by 46
The Patient-Centered Medical Home Movement
Larson, E. B., & Reid, R. J. (2010) · JAMA · doi:10.1001/jama.2010.524 · Cited by 45
Self-Management Support in Chronic Illness Care: A Concept Analysis
Kawi, J. (2012) · Research and theory for nursing practice · doi:10.1891/1541-6577.26.2.108 · Cited by 49
Rief, J., Hamm, M., Zickmund, S. L., Nikolajski, C., Lesky, D., Hess, R., Fischer, G. S., Weimer, M. B., Clark, S., Zieth, C. R., et al. (2016) · Health Communication · doi:10.1080/10410236.2016.1138378 · Cited by 46
“Second, “ partnership ” provides patients with opportunities to work with their healthcare team to address problems and achieve desired health outcomes (Bodenheimer et al., 2002; Gordon & Edwards, 1995; Rubinelli et al., 2009; Von Korff et al., 1997; Wagner et al., 2001).”
BackgroundInfluentialLudman, E. J., Simon, G. E., Grothaus, L. C., Luce, C., Markley, D. K., & Schaefer, J. K. (2007) · Psychiatric Services · doi:10.1176/ps.2007.58.8.1065 · Cited by 46
Self-citationWhy Do Some Primary Care Practices Engage in Practice Improvement Efforts Whereas Others Do Not?
Goldberg, D. G., Mick, S. S. F., Kuzel, A. J., Feng, L. B., & Love, L. E. (2012) · Health Services Research · doi:10.1111/1475-6773.12000 · Cited by 44
Collaborative care in schools: enhancing integration and impact in youth mental health
Lyon, A. R., Whitaker, K. M., French, W. P., Richardson, L. P., Wasse, J. K., & McCauley, E. (2016) · Advances in School Mental Health Promotion · doi:10.1080/1754730x.2016.1215928 · Cited by 46
Bogardus, S. T., Bradley, E. H., Williams, C. S., Maciejewski, P. K., Gallo, W. T., & Inouye, S. K. (2003) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2004.52017.x · Cited by 42
“Recommendations followed, % 0–25 9 (5) 26–50 36 (21) 51–75 48 (27) 76–100 83 (47) 100 66 (38)”
Metadata
- Authors
- Von Korff, M., Gruman, J., Schaefer, J., Curry, S. J., & Wagner, E. H.
- Affiliations
- From Group Health Cooperative of Puget Sound, Seattle, Washington; and the Center for the Advancement of Health, Washington, D.C.
- Group Health Cooperative (US)
- Venue
- Annals of Internal Medicine
- Publisher
- American College of Physicians
- Published
- 1997-12-15
- Volume
- 127
- Issue
- 12
- Pages
- 1097-1102
- ISSN
- 0003-4819 (ISSN-L)
- 1539-3704
- OpenAlex
- W2048179962
- Cited by
- 1,269
- References
- 0
- Citations by year
- 2026: 5 · 2025: 14 · 2024: 25 · 2023: 24 · 2022: 23 · 2021: 28 · 2020: 30 · 2019: 52 · 2018: 41 · 2017: 46 · 2016: 47 · 2015: 43 · 2014: 47 · 2013: 59 · 2012: 65
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Annals of Internal Medicine (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Epidemiology › Chronic Disease Management Strategies
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
- Health Sciences › Health Professions › General Health Professions › Patient-Provider Communication in Healthcare
- Keywords
- chronic disease, collaborative care, patient-provider relationship, self-care, self-management education, goal setting, action planning, patient preferences, follow-up care, health behavior change, emotional support, preventive medicine
- MeSH terms
- Chronic Disease, Follow-Up Studies, Humans, Patient Care Planning, Patient Care Team, Patient Education as Topic, Self Care, Social Support, Health Behavior, Practice Guidelines as Topic
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