Implementing Evidence-Based Patient Self-Management
Programs in the Veterans Health Administration: Perspectives
on Delivery System Design Considerations
T. M. Damush, PhD1,7, G. L. Jackson, PhD2, B. J. Powers, MD2, H. B. Bosworth, PhD2, E. Cheng, MD3,
J. Anderson, ANP, PhD4, M. Guihan, PhD5, S. LaVela, PhD5, S. Rajan, PhD6, and L. Plue, MA1
1Richard L. Roudebush VAMC, VA Stroke QUERI Center and HSRD COE, Indiana University Dept of General Internal Medicine and Geriatrics(
Center for Aging Research, Regenstrief Inc., Indianapolis, IN, USA;2HSRD COE( Durham VAMC, Durham, NC, USA;3VA Greater Los Angeles
Healthcare System, Los Angeles, CA, USA;4Neurology( Michael E. DeBakey VAMC, Houston, TX, USA;5Edward Hines Jr. VAMC, Spinal Cord
Injury QUERI Center, Chicago, IL, USA;6VA Puget Sound Health Care System, Spinal Cord Injury QUERI Center, Seattle, WA, USA;7Roudebush
VAMC, Indianapolis, IN, USA.
While many patient self-management (PSM) programs
have been developed and evaluated for effectiveness,
less effort has been devoted to translating and system-
atically delivering PSM in primary and specialty care.
Therefore, the purpose of this paper is to review delivery
system design considerations for implementing self-
management programs in practice. As lessons are learned
about implementing PSM programs in Veterans Health
Administration (VHA), resource allocation by healthcare
organization for formatting PSM programs, providing
patient access, facilitating PSM, and incorporating sup-
port tools to foster PSM among its consumers can be
refined and tailored. Redesigning the system to deliver
and support PSM will be important as implementation
researchers translate evidence based PSM practices into
routine care and evaluate its impact on the health-related
quality of life of veterans living with chronic disease.
KEY WORDS: self-management; implementation;
veterans health administration.
J Gen Intern Med 25(Suppl 1):68–71
© Society of General Internal Medicine 2009
During the past several decades, patient-self management
(PSM) programs have been developed to foster self care among
patients with chronic disease.1–5Variation exists in terms of
the program components, location of the program with the
health care system and staff involvement.6Experts define PSM
as strategies that enable the patient’s ability to monitor and
manage daily health and symptoms, to problem-solve to over-
come barriers encountered, to modify lifestyle risk factors, and to
communicate with clinical providers as active collaborators in
defining and adhering to health and therapeutic goals.1,2,7–9
The evidence on the effectiveness of (PSM) programs varies
across chronic conditions. Randomized controlled trials of
PSM programs have demonstrated improvements in outcomes
for chronic medical conditions10including asthma;11low back
Moreover several meta-analyses have reported that PSM
programs have produced clinically meaningful outcomes for
patients with diabetes and hypertension, but not for patients
with osteoarthritis where the outcome was pain control.20,21
However, a recent meta-analysis demonstrated that psycho-
logical interventions which included cognitive-behavioral and
self-regulatory components had positive effects on pain inten-
sity and interference, depression and health-related quality of
life among patients with chronic pain.22
In addition, PSM programs offer patients options and
strategies for coping with chronic medical conditions in order
to function daily and maintain health-related quality of life.
Patients with chronic disease are often left on their own to cope
and manage their symptoms in between medical visits.23
While many programs have been developed24and evaluated
for efficacy,12,16fewer efforts have been devoted to translating
these programs for delivery to patients. Therefore, the purpose
of this paper is to review delivery system design considerations
for implementing PSM programs into practice and to describe
our experiences in an integrated national healthcare organiza-
tion. The presented themes emerged from a workshop on this
topic at the (VHA) QUERI (QUality Enhancement Research
Initiative)25meeting held in December 2008 where three
presenters discussed their implementation work in progress
for hypertension26and stroke self management.27,28
Implementation of PSM Programs into Practice
For the purpose of this paper, we define implementation as the
systematic delivery of a PSM program within an organization
by dedicated personnel for qualified patients as an adopted
usual care protocol.29
Our implementation goals at the VA for PSM are threefold.
First, PSM program designers will collaborate with key VA
stakeholders (i.e., front line clinical providers, patients) to assist
with the local adoption of evidence based PSM programs that
address patient needs. Second, VA implementation researchers
will evaluate the implementation process of adopting PSM into
practice. Finally, effective PSM programs that are successfully
adopted by VAwill be sustained by the organization.
Example of a PSM at the VA
An example of one PSM at the VA is VSTITCH [The Veterans’
Study to Improve the Control of Hypertension], a PSM program
designed to assist patients with uncontrolled hypertension and
has demonstrated effectiveness in improving hypertension.15
In this program, a member of the clinical staff is guided
through a computer assisted telephone protocol to assist
patients in making lifestyle changes and adhering to thera-
peutic regimens. Bosworth and colleagues are currently
evaluating the adoption of VSTITCH into primary care services
across several VA facilities.
Delivery System Design Considerations
During the progression from effectiveness to implementation
research, there are several key delivery system design issues to
consider including designing the format of the PSM program,
defining targeted recipients of PSM, defining the facilitators of
and access to PSM, and specifying support tools to implement
Format of PSM. Several approaches to self-management
support have demonstrated promising results. A number of
studies have shown that the format of a PSM can be tailored to
best reach its recipients and to utilize space and personnel
efficiently while maintaining effectiveness. PSM programs have
been delivered in individual sessions by telephone;13,18in
group sessions of persons with chronic medical conditions;10
by shared, group medical visits;31by teleconference
groups;32,33and by virtual groups via the internet.11,18,34,35
A VA hospital may cover a wide range of geographic area,
limiting the frequency for which veteran patients may be able
to attend PSM programs. Thus, the format for which PSM is
offered may affect its reach into the targeted recipient popula-
tion. In VHA [Veterans Health Administration], community-
based outpatient clinics (CBOCs) are smaller facilities that
typically focus on delivering primary care services closer to
patients’ homes that may support PSM programs and reach a
larger volume of veteran patients.
Targeted Recipients for PSM. The principles and methods of
self-management support in chronic disease interventions
may be similar across different diseases, and the benefits of a
PSM intervention may extend beyond the intended targets.
One study reported a significant improvement in glycemic
control due to the nurse telephone intervention addressing
hypertension.36This hypertension intervention produced a
similar standardized effect size on glycemic control as PSM
interventions focused on diabetes, suggesting there are likely
common features of PSM support that transcend our usual
disease-focused interventions. This finding is encouraging for
the integration of PSM support within primary care where
many patients have multiple chronic conditions.
Facilitators of PSM. A central component of implementing a
PSM program is establishing facilitators within the healthcare
system.37First, organizations need to establish how patients
can best access the PSM programs. When implementing PSM
programs, organizations need to move away from recruitment
of participants and consider giving direct-to-consumer access
with referrals from multiple services (e.g., primary care,
rehabilitation) to support the patient PSM programs. Second,
providers are an important resource and influence on patient
care decisions.30With each medical visit, providers have the
opportunity to refer patients to PSM programs and discuss its
While it is important for clinicians to encourage patient
participation in programs, PSM skills may be developed and
reinforced during routine clinic visits. Clinical encounters
between patients and providers may be structured to encourage
this partnerships approach. One mechanism that supports this
approach is clinical decision support tools within the electronic
medical record. For example, the Self-management TO Prevent
(STOP) Stroke Tool28systematically guides providers in PSM
counseling during a clinical patient encounter. PSM teaching is
centered on stroke risk factor reduction and providers are
prompted on collaborative action planning, problem solving,
and decision making with the patient during the clinic visit. The
PSM counseling that were completed by the provider.28
To systematically facilitate provider PSM interaction, the
leadership of the healthcare organization will need to assign
clinical providers to include the administration of PSM in their
scope of duties or add new staff to specifically perform these
tasks. To illustrate, a nurse practitioner (NP) arranged shared,
group medical visits, coordinated interdisciplinary care for
diabetic patients and followed up with patients who missed
clinic visits by telephone to foster PSM.31PSM facilitation was
part of the NP scope of duties.
Support Tools. Support tools refer to any device that may assist
clinical providers in facilitating PSM.38,39Support tools such
as electronic templates in CPRS (Computerized Patient Record
System) may enhance PSM facilitation. CPRS is the VA
electronic record system that all providers use, contains
scheduling, medication, vitals, consults, reports, and can
accommodate clinical reminders.
CPRS offers clinical reminders that are triggered based upon
patient clinical criteria which clinicians must address during
the medical visit. However, provider feedback indicates that
there has been a proliferation of clinical reminders developed
targeting performance measures and as a result, providers
may gradually become desensitized to their use.
Home telemonitoring of patients with chronic disease has
been viewed as a valuable tool in promoting PSM and is
currently being tested in VA for improving hypertension care40
and pressure ulcer prevention in veterans with spinal cord
injury. One of the important early lessons has been the
feasibility of home telemonitoring in a veteran population.
During the first six months of a self-management trial using
home telemonitoring, 693 technical alerts documenting some
alteration in home monitoring protocols were generated by 267
participants; 61% of the total alerts were attributed to patient
non-adherence to the blood pressure monitoring protocol. This
level of difficulty with home monitoring procedures will need to
be considered should home monitoring become a component
of future PSM interventions.41Telemedicine interventions that
rely on advanced telemonitoring may be limited in their
applicability to the many patients with complex chronic ill-
nesses who struggle to properly use this equipment. Similarly,
Damush et al.: Perspectives on Delivery System Design Considerations
a recent trial comparing the use of videophones to telephones
for delivery of a chronic heart failure support program found
that veterans experienced equipment use difficulties with
Several factors are important to fostering PSM in VHA: tool
availability, ease of use, effectiveness, and cost. VHA has been
a leader in health information technology. Simple devices, e.g.
pedometers, have been shown to increase physical activity and
reduce weight and blood pressure.44Thus, VA facilities across
the organization currently supply veteran patients with pedo-
meters to foster behavior modification when prescribed by the
VA clinical provider. However the rate of systematic implemen-
tation of pedometer prescription by clinical providers is
unknown. For direct-to-consumer promotion of pedometer
use for PSM, a VA team has developed an internet-based
program to motivate and monitor pedometer use among
Another PSM support tool is my My HealtheVet (MHV). MHV
is the internet based personal health record created by VA for
veterans to manage their care. Spinal Cord Injury (SCI) QUERI
is collaborating with the SCI/D and MHV program offices to
create a healthy living information center on MHV dedicated to
PSM in persons with spinal cord injury.45Thus, support tools
can extend the care of the healthcare organization to reach a
larger portion of its consumers and provide PSM support
during and in between medical visits.
COMPARISON OF VA TO OTHER INTEGRATED
HEALTH CARE SYSTEMS’ PSM IMPLEMENTATION
Similar to other integrated healthcare systems (e.g., Kaiser
Permanente). VHA is a capitated national system that provides
care across the continuum of health within limited resources
per patient. These integrated healthcare systems invest in and
utilize health information technology to communicate, share
information and manage care within their network. Moreover,
these organizations invest in programs and tools that foster
the wellbeing of their patient population given the long term
service relationship with its patient population. Kaiser Perma-
nente recently announced that it is assessing patient physical
activity level at each medical visit and entering this data into
their electronic medical record system to foster PSM during
patient visits.46Similarly, both VHA and Kaiser Permanente
have begun to utilize support services to foster PSM. In some
VA sites, primary care has begun to implement patient
counseling by pharmacy for patients with uncontrolled hyper-
tension. VA researchers Bosworth and Kerr are currently
examining PSM administered by pharmacists in VHA and
As lessons are learned about implementing PSM programs in
VHA, resource allocation towards formatting PSM programs,
providing patient access, facilitating PSM, and incorporating
support tools to foster PSM among its consumers can be
refined by the healthcare organization. Redesigning the system
to deliver and support PSM will be important as implementa-
tion researchers collaborate with key stakeholders to translate
evidence based PSM practices into routine care and evaluate
its impact on health-related quality of life of veterans living
with chronic disease.
Acknowledgements: The project was supported in part by the
following funding: VA HSRD STR-03–168 (Stroke QUERI Center);
HSRD IMV#04–096 (Dr. Damush/Ms. Plue);NINDS/NIH Career
Development Award (5K23NS058571–03) to Dr. Eric Cheng; VA
senior career award to Dr. Bosworth; and a NCRR/NIH career
development award KL2 RR024127 to Dr. Ben Powers and the
National HSRD VA QUERI Program (Workshop sponsor).
Conflict of Interest: None disclosed.
Corresponding Author: T. M. Damush, PhD; Roudebush VAMC,
1481 W 10th St, HSRD 11H, Indianapolis, IN 46202, USA
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