Chronic Disease Self-Management (CDSM)

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ô Chronic disease self-management

The National Chronic Disease Strategy policy document defines self-management as:

"...the active participation by people in their own health care. Self-management incorporates health promotion and risk reduction, informed decision making, care planning, medication management, and working effectively with health care providers to attain the best possible care and to effectively negotiate the often complex health system."

 There are other definitions, but the common premise is the active involvement of individuals in the management of their own health.

 ’...you find out they were dying because they weren’t educated about diabetes...the next thing all these modules and courses and information is available....tell you what to eat and how to look after yourself. By doing all these courses and meetings we are showing the next generation what it is all about. We are throwing them a lifeline. We would all be six feet under if we weren’t educated and took responsibility for our health. You can tell us everything about diabetes but it is up to the individual to decide what they should do.’
 Aboriginal Elder, Look, Think, Act Project, Port Lincoln Aboriginal Health Service

In this guide chronic disease self-management (CDSM) and self-management are synonymous.  In the chronic disease context, self-management involves making choices or adopting behaviours that:

The term chronic condition self-management (CCSM) is sometimes used in preference to chronic disease self-management (CDSM) negating the distinction between actual diseases, for example diabetes, and chronic conditions, for example chronic pain. Consumers prefer the term ‘condition’ over ‘disease’ because of the negative connotations associated with latter.  Some health care providers also avoid ‘disease’ because it implies a negative view of health.  To be to be consistent with recent State and Commonwealth Government policy statements, this guide uses the term chronic disease self-management and its acronym CDSM, or simply self-management.

CDSM is not about leaving people to care for themselves. It is not about self-diagnosis, nor about people organising their own treatment. CDSM is not only about the individual. CDSM also involves their family, carers, community, service providers and health care services all working together to minimise the impact of chronic disease on the individual.

Australian and overseas research on chronic disease self-management has reported positive short-term impacts on individuals, health systems and health care providers including:

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ô Characteristics of a 'good' self-manager

 People vary in their readiness, willingness and ability to self-manage. The following are the characteristics of a 'good' self-manager. These characteristics have been adapted from the six principles of self-management described in the Flinders Model of Chronic Condition Self-Management.

A 'good' self-manager:

  1. knows about their condition, its causes, consequences, risk factors and the recommended care and screening regimes. They know how to reduce the risk of complications and disease progression. They know what medications they are taking and why these were prescribed. They know enough about their condition to negotiate a plan of care with their health care provider.
  2. is actively involved in decision making with their health care provider, with whom they have an honest and open relationship. This relationship is a partnership and is not based on the traditional 'expert/client' roles.
  3. follows a treatment plan that they have negotiated with their health care provider(s). They take medications as prescribed, note side effects and inform their doctor and pharmacist of any adverse reactions that they may experience.
  4. monitors and responds to any signs or symptoms of their condition in accordance with their treatment plan. A client with asthma, for example, uses a peak flow meter regularly to monitor their condition and adjusts their medication, if required, according to their Asthma Management Plan.
  5. manages and minimises negative impacts of their condition on their social relationships, emotions and physical functioning.
  6. adopts a healthy lifestyle, eats an appropriate diet and does an appropriate amount of exercise. They avoid smoking and excess alcohol, and take action to avoid or minimise unhealthy behaviours.

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ô Self-management support

If self-management is what an individual does to manage their chronic disease, then self-management support is what health care providers and others do to assist that individual to self-manage. This guide defines self-management support as:

  • any service, assistance or education provided by the health, community, or education sectors that increases a person’s knowledge, skills and confidence to be fully involved in lifestyle and health care decisions to:

    • prevent or delay the onset of a chronic disease
    • manage their chronic disease to improve their health outcomes and quality of life

Self-management support empowers people with the skills, knowledge and confidence to participate fully with others, including health care providers, to solve problems, make decisions, build relationships and tailor their lives to suit their circumstances..

  • health concerns are not always central in peoples’ lives
  • apart from individual behaviour and lifestyle choices, there are a whole range of social, environmental and biological determinants of health

CDSM support is about helping people to help themselves regardless of their circumstances.

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ô The need to promote and support self-management

The 2003 SA Generational Health Review reported that 450,000 South Australians have at least one preventable chronic disease. The review further stated that 70% of the overall current disease burden in SA is due to chronic disease and that this is expected to rise to 80% by 2020. The situation for Australia is no different.  In 2000-01, diagnosis and management of chronic disease accounted for 70% of all health expenditure in Australia. 

"Effective responses to this significant health challenge must be found to protect the quality of life and well-being of all Australians"
 National Chronic Disease Strategy

Current service delivery and funding arrangements focus on acute and short-term responses rather than prevention, detection, and early intervention.

"There is an urgent need to identify practical and achievable approaches to develop Australia’s health system to meet current and future demands for chronic disease prevention and care."
 National Chronic Disease Strategy

Click image for a larger version

The actions recommended by the National Chronic Disease Strategy reflect the theme of chronic disease prevention and care and the need to move from acute care models to more preventative and patient-centred models. The actions include:

  • effective health promotion and risk reduction strategies across the continuum of chronic disease prevention and care
  • early detection to support early treatment, improved health outcomes and therefore improvements in the quality of life for people with chronic disease
  • improved collaborations between health services, patients, their families and carers to provide patient-centred, integrated and continuous care
  • support for people, their families and carers to develop skills and resources to maximise their capacity to self-manage

 

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ô Tools and strategies to support self-management 

Support for CDSM requires an effective range of tools and strategies to inform, assist, and empower clients.

Some of the support strategies, along with their associated tools, are outlined in Section Two of this guide. The strategies covered are the prevention and early detection of chronic disease, patient-centred care planning, self-management courses, community participation and community development.

The tools and strategies come from the various medical, behavioural or socio-economic models of health promotion.

  • The medical model can contribute health assessments, screenings, diagnostic tools, disease registers, recall systems, protocols for best practice service provision, symptom action plans and medications.
  • The behavioural model can contribute generic and disease-specific self-management training, patient-centred care planning, behavioural therapies, as well as exercise, nutrition and lifestyle education.
  • The socio-economic model offers recognition of the need for individual and community empowerment, community development, and community participation in designing and providing appropriate, supportive and health promoting strategies.

Although few individual health services, including General Practice, are in a position to offer the whole range of support strategies, co-operation between providers and sectors can assist in meeting the support needs of individuals with chronic disease. The case studies provided in Section Three of this guide report a range of models designed to provide, coordinate and integrate self-management support services.

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ô Relationships to support self-management

Many health care providers and health services are involved in supporting an individual with chronic disease. In this guide we have used the term health care provider  as the collective term for the range of support personnel. This includes medical practitioners and specialists, nurses and allied health professionals, pharmacists, health educators, community health workers, social workers and Aboriginal Health Workers. Reference to a specific type of provider, for example, a General Practitioner (GP) is made where appropriate.

Regardless of the heath care provider involved, support for the person with chronic disease requires the adoption of a respectful, collaborative and client-centred approach that utilises a range of motivational, communication and support skills. 

Research indicates that successful strategies to improve self-management require client involvement in targeting, goal setting and planning. The provider/client relationship should be an equal collaboration, with the health care provider contributing expertise about chronic disease and its treatment, and the client contributing expertise about their lives, their priorities and what treatment options are realistic. Health care providers also need to work collaboratively with families, carers and other service providers as appropriate.

For GPs, self-management means working as part of multi-disciplinary teams, delegating to other personnel some of the work load associated with routine patient management.  GPs are being encouraged to coordinate the care of clients by working with the client, and other health care providers, to plan and provide appropriate levels of care. This primary health care team strategy encourages a more patient-centred and shared approach to the management of chronic disease.

"GPs cannot physically do everything anymore…is it doubtful whether they ever could.
GP involved in SA HealthPlus

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ô References

  1. Battersby, M. 2005, Health reform through coordinated care: SA HealthPlus, British Medical Journal, vol. 330, pp. 662-665.

  2. Martin B. Notes on some concepts commonly used for analysis of social relationships and systems, University of Wollongong [Online, accessed 25 May 2007]

  3. Lorig K. & Holman H. 2003, Self-management education: history, definition, outcomes, and mechanisms, Ann Behav Med, vol. 26, no. 1, pp. 1-7.

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