Cited by 1,269Chronic Disease Management StrategiesDiabetes Management and EducationPatient-Provider Communication in Healthcare

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Collaborative Management of Chronic Illness

Von Korff, Michael, Gruman, Jessie, Schaefer, Judith, Curry, Susan J., Wagner, Edward H.·1997·Annals of Internal Medicine

DOI 10.7326/0003-4819-127-12-199712150-00008

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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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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
DOI: 10.7326/0003-4819-127-12-199712150-00008
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
Licence: www.acpjournals.org/journal/aim/text-and-data-mining (tdm)
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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