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PERSPECTIVE

Collaborative Management of Chronic Illness

right arrow Michael Von Korff, ScD; Jessie Gruman, PhD; Judith Schaefer, MPH; Susan J. Curry, PhD; and Edward H. Wagner, MD, MPH

15 December 1997 | Volume 127 Issue 12 | Pages 1097-1102

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.

Author and Article Information
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From Group Health Cooperative of Puget Sound, Seattle, Washington; and the Center for the Advancement of Health, Washington, D.C.
Acknowledgments: The authors thank Teresa Fama, Russ Glasgow, Halstead Holman, Elizabeth Lin, Kate Lorig, and Richard Sloan.
Grant Support: By "Critical Next Steps to Improve Collaborative Management of Chronic Illness," a conference grant from the Robert Wood Johnson Foundation.
Requests for Reprints: Michael Von Korff, ScD, Center for Health Studies, Group Health Cooperative of Puget Sound, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101.
Current Author Addresses: Drs. Von Korff, Curry, and Wagner and Ms. Schaefer: Center for Health Studies, Group Health Cooperative of Puget Sound, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101.

 

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J. Bourbeau, M. Julien, F. Maltais, M. Rouleau, A. Beaupre, R. Begin, P. Renzi, D. Nault, E. Borycki, K. Schwartzman, et al.
Reduction of Hospital Utilization in Patients With Chronic Obstructive Pulmonary Disease: A Disease-Specific Self-management Intervention
Arch Intern Med, March 10, 2003; 163(5): 585 - 591.
[Abstract] [Full Text] [PDF]


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Psychiatr. Serv.Home page
P. P. Roy-Byrne, C. D. Sherbourne, M. G. Craske, M. B. Stein, W. Katon, G. Sullivan, A. Means-Christensen, and A. Bystritsky
Moving Treatment Research From Clinical Trials to the Real World
Psychiatr Serv, March 1, 2003; 54(3): 327 - 332.
[Abstract] [Full Text] [PDF]


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Arch Intern MedHome page
G. F. Anderson
Physician, Public, and Policymaker Perspectives on Chronic Conditions
Arch Intern Med, February 24, 2003; 163(4): 437 - 442.
[Abstract] [Full Text] [PDF]


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ANN INTERN MEDHome page
A. A. Rothman and E. H. Wagner
Chronic Illness Management: What Is the Role of Primary Care?
Ann Intern Med, February 4, 2003; 138(3): 256 - 261.
[Abstract] [Full Text] [PDF]


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Journals of Gerontology Series A: Biological Sciences and Medical SciencesHome page
M. Hewitt, J. H. Rowland, and R. Yancik
Cancer Survivors in the United States: Age, Health, and Disability
J. Gerontol. A Biol. Sci. Med. Sci., January 1, 2003; 58(1): M82 - 91.
[Abstract] [Full Text] [PDF]


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Diabetes CareHome page
C. Mensing, J. Boucher, M. Cypress, K. Weinger, K. Mulcahy, P. Barta, G. Hosey, W. Kopher, A. Lasichak, B. Lamb, et al.
National Standards for Diabetes Self-Management Education
Diabetes Care, January 1, 2003; 26(90001): s149 - 156.
[Full Text] [PDF]


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JAMAHome page
T. Bodenheimer, K. Lorig, H. Holman, and K. Grumbach
Patient Self-management of Chronic Disease in Primary Care
JAMA, November 20, 2002; 288(19): 2469 - 2475.
[Abstract] [Full Text] [PDF]


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BMJHome page
K. Rost, P. Nutting, J. L Smith, C. E Elliott, and M. Dickinson
Managing depression as a chronic disease: a randomised trial of ongoing treatment in primary care
BMJ, October 26, 2002; 325(7370): 934 - 934.
[Abstract] [Full Text] [PDF]


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Am. J. PsychiatryHome page
M. M. Desai, R. A. Rosenheck, B. G. Druss, and J. B. Perlin
Mental Disorders and Quality of Diabetes Care in the Veterans Health Administration
Am J Psychiatry, September 1, 2002; 159(9): 1584 - 1590.
[Abstract] [Full Text] [PDF]


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JAMAHome page
D. Schillinger, K. Grumbach, J. Piette, F. Wang, D. Osmond, C. Daher, J. Palacios, G. D. Sullivan, and A. B. Bindman
Association of Health Literacy With Diabetes Outcomes
JAMA, July 24, 2002; 288(4): 475 - 482.
[Abstract] [Full Text] [PDF]


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Psychosom. Med.Home page
P. S. Ciechanowski, E. A. Walker, W. J. Katon, and J. E. Russo
Attachment Theory: A Model for Health Care Utilization and Somatization
Psychosom Med, July 1, 2002; 64(4): 660 - 667.
[Abstract] [Full Text] [PDF]


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Arch Pediatr Adolesc MedHome page
J. A. Finkelstein, P. Lozano, H. J. Farber, I. Miroshnik, and T. A. Lieu
Underuse of Controller Medications Among Medicaid-Insured Children With Asthma
Arch Pediatr Adolesc Med, June 1, 2002; 156(6): 562 - 567.
[Abstract] [Full Text] [PDF]


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JAMAHome page
M. E. Tinetti, D. Baker, W. T. Gallo, A. Nanda, P. Charpentier, and J. O'Leary
Evaluation of Restorative Care vs Usual Care for Older Adults Receiving an Acute Episode of Home Care
JAMA, April 24, 2002; 287(16): 2098 - 2105.
[Abstract] [Full Text] [PDF]


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West J Nurs ResHome page
J. M. Lenoci, J. Telfair, H. Cecil, and R. R. Edwards
Self-Care in Adults with Sickle Cell Disease
West J Nurs Res, April 1, 2002; 24(3): 228 - 245.
[Abstract] [PDF]


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Diabetes CareHome page
P. S. Ciechanowski, I. B. Hirsch, and W. J. Katon
Interpersonal Predictors of HbA1c in Patients With Type 1 Diabetes
Diabetes Care, April 1, 2002; 25(4): 731 - 736.
[Abstract] [Full Text] [PDF]


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JAMAHome page
M. W. Rich
From Clinical Trials to Clinical Practice: Bridging the GAP
JAMA, March 13, 2002; 287(10): 1321 - 1323.
[Full Text] [PDF]


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West J Nurs ResHome page
J. Leeman, J. S. Harrell, and S. G. Funk
Building a Research Program Focused on Vulnerable People
West J Nurs Res, February 1, 2002; 24(1): 103 - 111.
[PDF]


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Health Aff (Millwood)Home page
E. H. Wagner, B. T. Austin, C. Davis, M. Hindmarsh, J. Schaefer, and A. Bonomi
Improving Chronic Illness Care: Translating Evidence Into Action
Health Aff., November 1, 2001; 20(6): 64 - 78.
[Abstract] [Full Text] [PDF]


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BMJHome page
J. Cheah
Chronic disease management: a Singapore perspective
BMJ, October 27, 2001; 323(7319): 990 - 993.
[Full Text] [PDF]


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BMJHome page
H. A Wolpert and B. J Anderson
Management of diabetes: are doctors framing the benefits from the wrong perspective?
BMJ, October 27, 2001; 323(7319): 994 - 996.
[Full Text] [PDF]


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Diabetes CareHome page
A. C. Larme and J. A. Pugh
Evidence-Based Guidelines Meet the Real World: The case of diabetes care
Diabetes Care, October 1, 2001; 24(10): 1728 - 1733.
[Abstract] [Full Text] [PDF]


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Arch Pediatr Adolesc MedHome page
D. M. D'Alessandro and N. P. Dosa
Empowering Children and Families With Information Technology
Arch Pediatr Adolesc Med, October 1, 2001; 155(10): 1131 - 1136.
[Abstract] [Full Text] [PDF]


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Fam PractHome page
C. Brown, J. Dunbar-Jacob, D. R Palenchar, K. J Kelleher, R. D Bruehlman, S. Sereika, and M. E Thase
Primary care patients' personal illness models for depression: a preliminary investigation
Fam. Pract., June 1, 2001; 18(3): 314 - 320.
[Abstract] [Full Text] [PDF]


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Arch Intern MedHome page
I. M. El-Kebbi, D. C. Ziemer, C. B. Cook, C. D. Miller, D. L. Gallina, and L. S. Phillips
Comorbidity and Glycemic Control in Patients With Type 2 Diabetes
Arch Intern Med, May 28, 2001; 161(10): 1295 - 1300.
[Abstract] [Full Text] [PDF]


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ANN INTERN MEDHome page
M. Von Korff and J. C. Moore
Stepped Care for Back Pain: Activating Approaches for Primary Care
Ann Intern Med, May 1, 2001; 134(9_Part_2): 911 - 917.
[Abstract] [Full Text] [PDF]


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Diabetes CareHome page
S. L. Norris, M. M. Engelgau, and K.M. Venkat Narayan
Effectiveness of Self-Management Training in Type 2 Diabetes: A systematic review of randomized controlled trials
Diabetes Care, March 1, 2001; 24(3): 561 - 587.
[Abstract] [Full Text]


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GerontologistHome page
J. J. Angelelli, K. H. Wilber, and R. Myrtle
A Comparison of Skilled Nursing Facility Rehabilitation Treatment and Outcomes Under Medicare Managed Care and Medicare Fee-for-Service Reimbursement
Gerontologist, December 1, 2000; 40(6): 646 - 653.
[Abstract] [Full Text]




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