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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
From Group Health Cooperative of Puget Sound, Seattle, Washington; and the Center for the Advancement of Health, Washington, D.C.
PERSPECTIVE
Collaborative Management of Chronic Illness
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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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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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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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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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J. Cheah Chronic disease management: a Singapore perspective BMJ, October 27, 2001; 323(7319): 990 - 993. [Full Text] [PDF] |
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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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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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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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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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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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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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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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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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