By Melinda Young
People with chronic diseases were more engaged — regardless of depression or anxiety — when enrolled in a chronic disease self-management education program.1
Sometimes, patients do not manage their conditions well because they are mismatched with the health system, says Marcia G. Ory, PhD, MPH, a regents and distinguished professor at Texas A&M University School of Public Health.
“Doctors [and] clinicians want to do their best for their patients, but they don’t have the time it takes to walk everyone through what is involved in self-management,” Ory explains. “Conditions like diabetes management just aren’t going to be controlled by three to four visits every year to the clinician — or even [with] monthly visits.”
Patients have to learn how to manage their condition on their own. That is why self-management programs are helpful and successful.
“[Providers] work with people on setting their goals, monitoring when they come upon challenges, whether it’s their diet or exercise,” Ory says. “They work with families and manage distress.”
Clinicians play a major role in helping patients with chronic illnesses. They could refer patients to programs that provide more education. “The biggest barrier is clinicians don’t have time to [conduct] self-management training in their own clinics. Often, they don’t have the time, or know where in the community that programs are available for referral,” Ory says. “There are evidence-based programs that are low-cost or minimal cost to clients, and sometimes they’re paid through insurance.”
For patients who lack insurance coverage for these programs, many Area Agencies on Aging offer diabetes management programs. “If you’re in a small, rural area, a lot of these classes are online because of COVID,” Ory says. “The point is the obstacle the commission faces is not having time in their own clinic and not knowing where to refer people.”
One example of a program that could help people improve their health is called Texercise.2 “It’s all about monitoring and controlling your eating and being active,” Ory says. Even though it’s Texas-bound, it is online, too.”
The program teaches the principles of self-management, including goal setting, problem-solving, monitoring behavior, and creating an action plan.
The best self-management education programs are based on the principles of behavior change, Ory says. “All of these programs have different names, but they are all based on the same self-management principles,” she explains. “Most of these programs are highly successful, they are collaborative, and they understand the context in which people live and what makes it harder for them to engage in healthy lifestyle behaviors.”
The key is identifying effective chronic disease management programs that could be useful to patients. One way to find these programs is to use the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework. RE-AIM was developed to improve health promotion interventions by considering real-world implementation.3,4
“RE-AIM helps you in planning programs as well as evaluating them,” Ory says.
Case management teams can use RE-AIM when planning whether to offer a chronic disease management program in house or evaluate existing community programs for referrals.
“It’s about understanding populations and what their chronic disease history profile is as well as cultural preferences,” Ory says. “You don’t want to shove a square program into a round population hole.”
The RE-AIM framework helps case managers identify populations in need and understand how representative a program is for that population. For instance, a chronic disease self-management program could be located in one geographical region but used almost exclusively by people with insurance at a higher education level. If the region it is representing has a large proportion of people with lower levels of education who are uninsured or underinsured, then the program is not fully benefiting the population it targets.
“RE-AIM helps you recognize how representative your program is,” Ory explains.
RE-AIM also could help case managers determine the effectiveness of a program — whether it is an in-house program or a community-based program. They could use the framework to study the program and ensure it is truly based on scientific evidence and could achieve the desired results.
Case managers also could consider the challenges their patients and their organizations face. “When you’re asking about the issues that clinicians face, everyone faces a problem, including people living with chronic disease and who have challenges, and clinicians who have challenges because of limited time,” Ory says. “Community organizations have problems because they may have programs that people don’t come to because of problems with the referral network.”
Solutions may be to improve each of the elements of reach, effectiveness, adoption, implementation, and maintenance.
“Get them delivered as created and maintain the gains at the individual level as well as the organizational level,” Ory says. “Make sure you’re reaching the populations in need.”
For example, a case manager could ask patients whether they have a goal toward self-management. “It doesn’t do any good for the case manager to say, ‘You need a better diet, you need to be more active, you need to take your meds.’ If you don’t help the person understand that your goal is their goal, it won’t work,” Ory notes. “The first thing to do is replicate these self-management programs and ask, ‘What is your goal?’”
A patient’s goal may have nothing to do with their health. It could be to simply attend their granddaughter’s wedding or to dance at a party, Ory says. “Find out what their goal is and work on an action plan that will enable them to achieve that goal,” she adds. “Say, ‘Let’s work on self-management that will help you get your diabetes under control.’”
Case managers can help patients set manageable goals. For example, they can start patients with small actions and build them up to 30 minutes of activity per day.
Ask patients what their problems are in achieving their goals. “If the patient says, ‘I can’t afford the food they want me to eat,’ then the case manager can say, ‘Let’s see if we can get you on food stamps,’ and help the person self-manage those problems,” Ory says.
Case managers are good at finding public and nonprofit resources to help patients with their social determinants of health obstacles.
“The person has to understand what needs to be done to keep any chronic condition under control,” Ory says.
Once patients understand the connection between their symptoms and their own daily behaviors, they are more likely to follow self-management tactics to improve their health.
REFERENCES
- Pullyblank K, Brunner W, Scribani M, et al. Recruitment and engagement in disease self-management programs: Special concerns for rural residents reporting depression and/or anxiety. Prev Med Rep 2022;26:101761.
- Texas Health and Human Services. Texercise.
- King DK, Glasgow RE, Leeman-Castillo B. Reaiming RE-AIM: Using the model to plan, implement, and evaluate the effects of environmental change approaches to enhancing population health. Am J Public Health 2010;100:2076-2084.
- Glasgow RE, Harden SM, Gaglio B, et al. RE-AIM planning and evaluation framework: Adapting to new science and practice with a 20-year review. Front Public Health 2019;7:64.
People with chronic diseases were more engaged — regardless of depression or anxiety — when enrolled in a chronic disease self-management education program.
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