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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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BackgroundElements of Effective Chronic Care: A Model for Optimizing Outcomes for the Chronically Ill
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Self-citationBourbeau, J. (2003) · Disease Management & Health Outcomes · doi:10.2165/00115677-200311050-00004 · Cited by 32
National Standards for Diabetes Self-Management Education
Mensing, C. R., Boucher, J. L., Cypress, M., Weinger, K., Mulcahy, K., Barta, P., Hosey, G. M., Kopher, W., Lasichak, A., Lamb, B., et al. (2003) · Diabetes Care · doi:10.2337/diacare.26.2007.s149 · Cited by 32
A Goal Attainment Pain Management Program for Older Adults with Arthritis
Davis, G. C., & White, T. L. (2008) · Pain Management Nursing · doi:10.1016/j.pmn.2008.02.007 · Cited by 30
Davis, C. L., Kilbourne, A. M., Blow, F. C., Pierce, J. R., Winkel, B. M., Huycke, E. J., Langberg, R., Lyle, D., Phillips, Y., & Visnic, S. (2012) · American Journal of Public Health · doi:10.2105/ajph.2011.300502 · Cited by 32
Professionalism and functional outcomes
Worrall, L. E. (2006) · Journal of Communication Disorders · doi:10.1016/j.jcomdis.2006.02.007 · Cited by 31
Pulmonary rehabilitation in the treatment of chronic obstructive pulmonary disease.
Nici, L. L., Lareau, S. C., & ZuWallack, R. (2010) · PubMed · Cited by 31
Bauer, M. S., Krawczyk, L., Tuozzo, K., Frigand, C., Holmes, S., Miller, C. J., Abel, E., Osser, D. N., Franz, A., Brandt, C., et al. (2018) · Telemedicine and e-Health · doi:10.1089/tmj.2017.0017 · Cited by 31
“21 CCMs are multicomponent models developed initially for chronic medical illnesses treated in primary care, 22,23 which now also have a strong evidence base across a wide variety of mental health conditions.”
Developing a Comprehensive Interdisciplinary Senior Healthcare Practice
Stock, R. D., Reece, D., & Cesario, L. (2004) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2004.52576.x · Cited by 30
“Beyond handing brochures to patients, self-management support is a recognition that the patient is ultimately in control and that providers need to inform, motivate, empower, and activate the patient.(17) Each SHWC patient receives a health manual(18) and an explanation of how to use it.”
BackgroundAdherence to Disease-Modifying Therapy in Multiple Sclerosis: Part II
Holland, N. J., Wiesel, P., Cavallo, P. F., Edwards, C., Halper, J., Kalb, R. C., Morgante, L., Namey, M., O'Leary, M. L., & Smith-Williamson, L. (2001) · Rehabilitation Nursing · doi:10.1002/j.2048-7940.2001.tb01959.x · Cited by 31
Diabetes Care Practices in Primary Care: Results from Two Samples and Three Measurement Sets
Glasgow, R. E., Boles, S. M., Calder, D., Dreyer, L., & Bagdade, J. D. (1999) · The Science of Diabetes Self-Management and Care · doi:10.1177/014572179902500508 · Cited by 31
Bao, Y., McGuire, T. G., Chan, Y.-F., Eggman, A. A., Ryan, A. M., BRUCE, M. L., Pincus, H. A., Hafer, E., & Unützer, J. (2017) · PubMed · Cited by 30
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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