Self-Management Services: Their Role in Disease Management
For people with chronic illness, day-to-day responsibilities for care fall most heavily on patients and their families. Organising healthcare to strengthen and support self-management in chronic illness while assuring that effective medical, preventative and health maintenance interventions take place is key to effective disease management. This paper discusses the behavioural principles and empirical evidence about healthcare designed to maximise positive patient participation in chronic disease care. Four main essential elements are key: 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, where patients and providers together agree on realistic objectives and set an action plan for attaining them; 3. availability of a continuum of self-management training and support options that teach patients the skills needed to carry out medical regimens, guide health behaviour change and provide emotional support; 4. active and sustained follow-up during which patients are contacted at specified intervals to monitor health status and reinforce progress in meeting care plan objectives. These elements constitute a common core of services and approaches that do not need to be replicated for each chronic condition.
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