October 15, 2005 ◆ Volume 72, Number 8?
American Family Physician 1503
in Patients with Chronic Illness
MARY THOESEN COLEMAN, M.D., PH.D., and KAREN S. NEWTON, M.P.H.
University of Louisville School of Medicine, Louisville, Kentucky
activity, and air pollution are associated with
an epidemic of chronic illness. Approxi-
mately 120 million Americans have one or
more chronic illnesses, accounting for 70 to
80 percent of health care costs. Twenty-five
percent of Medicare recipients have four or
more chronic conditions, accounting for
two thirds of Medicare expenditures.1,2 Most
patients with chronic conditions such as
hypertension, diabetes, hyperlipidemia, con-
gestive heart failure, asthma, and depres-
sion are not treated adequately, and the
burden of chronic illness is magnified by the
fact that chronic conditions often occur as
Physician support of patient self-manage-
ment is one of the key elements of a systems-
oriented chronic care model.4 Increasing
evidence shows that self-management sup-
port reduces hospitalizations, emergency
department use, and overall managed care
costs, although the cost of self-management
global rise in life expectancy and
an increase in cultural and envi-
ronmental risks such as smoking,
unhealthy diet, lack of physical
interventions in individual nonmanaged
care practices has yet to be determined.3,5-7 A
review7 of 41 studies assessing interventions
to improve diabetes outcomes in primary
care revealed that adding patient-oriented
interventions can lead to improvements
in outcomes such as glycemic control. In
36 trials focused on adult asthma, self-
management (self-monitoring coupled with
medical review and a written action plan)
produced greater reductions in nocturnal
symptoms, hospitalizations, and emer-
gency department use than did usual care.8
Another community-based group program,
designed to increase self-efficacy among
patients with diabetes, resulted in improved
self-efficacy and A1C levels.9 Despite this
encouraging evidence, self-management is
the least implemented and most challenging
area of chronic disease management.10
Although the terms patient self-manage-
ment, self-management support, and patient
education often are used interchangeably,
they do not have the same meaning. Self-
management is the ability of the patient to
deal with all that a chronic illness entails,
Support of patient self-management is a key component of effective
chronic illness care and improved patient outcomes. Self-management
support goes beyond traditional knowledge-based patient education to
include processes that develop patient problem-solving skills, improve
self-efficacy, and support application of knowledge in real-life situa-
tions that matter to patients. This approach also encompasses system-
focused changes in the primary care environment. Family physicians
can support patient self-management by structuring patient-physician
interactions to identify problems from the patient perspective, making
office environment changes that remove self-management barriers,
and providing education individually and through available com-
munity self-management resources. The emerging evidence supports
the implementation of practice strategies that are conducive to patient
self-management and improved patient outcomes among chronically
ill patients. (Am Fam Physician 2005;72:1503-10. Copyright © 2005
American Academy of Family Physicians.)
See editorial on
1504 American Family Physician
Volume 72, Number 8 ◆ October 15, 2005
including symptoms, treatment, physical and
social consequences, and lifestyle changes.11
With effective self-management, the patient
can monitor his or her condition and make
whatever cognitive, behavioral, and emo-
tional changes are needed to maintain a
satisfactory quality of life.11 Self-management
support is the process of making multi-
level changes in health care systems and the
community to facilitate patient self-manage-
ment.10,12 Patient education generally refers to
knowledge-based instructions for a specific
disease. Self-management education differs
from traditional patient education in what
is taught, how problems are formulated, the
relation of what is taught to the disease, and
the theory underlying the goal (Table 1).13
The theory underlying patient education is
that increasing a patient’s knowledge about
a disease leads to behavioral change that
improves clinical outcomes. An underlying
theory of self-management education is that
self-efficacy, or the patient’s belief in his
or her own ability to accomplish a specific
behavior or achieve a reduction in symp-
toms, leads to improved clinical outcomes.
Self-management support expands the role
of health care professionals from delivering
information to include helping patients build
confidence and make choices that lead to
SORT: Key RecOmmendaTiOnS fOR PRacTice
To support self-management, family physicians should address goal
setting and problem solving, make office system changes, provide
self-management education, and link the patient to community self-
Motivational interviewing is recommended as an effective way to
prevent relapse in alcohol dependence.
Weekly follow-up phone calls by a nurse manager and monthly calls
by a physician are recommended as a way to improve blood sugar
control and weight loss in patients with diabetes.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evi-
dence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information
about the SORT evidence rating system, see page 1435 or http://www.aafp.org/afpsort.xml.
components of Patient education and Self-management education
The rightsholder did not
grant rights to reproduce
this item in electronic
media. For the missing
item, see the original print
version of this publication.
October 15, 2005 ◆ Volume 72, Number 8?
American Family Physician 1505
improved self-management and better out-
comes. Patient education typically is given by
a health care professional; self-management
can be taught and supported by health care
professionals, office support staff, peer lead-
ers, and other patients.
The self-management challenges for per-
sons with chronic conditions can be divided
into three types: medical management,
role management, and emotional manage-
ment.13-15 Physicians who want to provide
increased support of their patients’ self-
management are advised to address three
areas: structuring patient-physician inter-
actions to include goal-setting and prob-
lem-solving strategies, making office system
changes, and providing self-management
education by linking patients to community
Practical applications for Physicians
There are many ways that physicians can
translate this evidence for self-management
support into daily practice. Primarily, this
involves a shift of focus away from clin-
ical outcomes (e.g., reducing A1C levels)
and toward providing help with the day-to-
day problems of living with chronic illness
(e.g., making healthful food selections in
restaurants). It may be useful for physicians
making this shift to remind themselves that,
for the patient, self-management is inevi-
table and already occurring.10,16 More specific
methods are discussed below, and summa-
rized in Table 2.
Motivational interviewing is an in-depth
approach to decision making intended to
help patients come to their own decisions
by exploring their uncertainties.
The interviewer uses directive
questions and reflective listening
to encourage the patient to par-
ticipate (Figure 1).17 This style
of interview, asking the patient
provocative questions and dis-
cussing the responses, often can
help uncover important self-
management issues, and has been proven
effective for preventing relapse in patients
with alcohol dependence.18
A common barrier to successful self-man-
agement is that chronic conditions often
occur as comorbidities. Patients with chronic
diseases who are asked to identify barri-
ers to self-management often cite examples
such as aggravation of one condition by
the symptoms or treatment of another, and
problems created by multiple medication reg-
imens.16,19,20 Physicians can help patients set
goals that will affect real-life challenges, rather
than disease-oriented goals. For example,
Steps to Support Self-management
in Patients with chronic illness
Address health literacy issues and medical
obstacles to self-management.
Identify problems from the patient’s
perspective by asking provocative questions
and listening to patient responses (Figure 1).
Include goal-setting, action-planning, and
problem-solving strategies to overcome
barriers based on the patient’s immediate
Link patients to community-based self-
Provide self-management education.
Follow up with patients systematically about
action plans and goals, in person, by phone,
or by e-mail.
Provide group visits that include self-
Schedule planned visits that allow time to
address self-management tasks.
Physicians can support
self-management by focus-
ing on helping patients
deal with the day-to-day
problems of living with
Sample Provocative Questions for Use in Planned visits
What are you afraid might happen as a result of your [fill in condition:
e.g., diabetes, asthma]?
Lots of patients have problems with medications. What problems have
Self-management decisions are “experiments” that will lead you to more
effective and satisfying management of your [condition]. Tell me about
a self-management “experiment” you tried that didn’t work out well.
Can you think of a self-management “experiment” you tried that worked
well and that you will continue to do?
figure 1. Sample of provocative questions for use in planned visits (from
author conversation with K. lorig, March 2003).
1506 American Family Physician
Volume 72, Number 8 ◆ October 15, 2005
a patient with diabetes and
asthma has limited ability to do
the exercise needed for diabetes
control; rather than focusing on
reducing A1C levels, the patient
could focus on breathing exer-
cises to improve daily comfort.
Additionally, the physician can address bar-
riers that have medical treatment options.
For example, if a patient with diabetes has
untreated depression, this may create a bar-
rier to effective self-management; treating
the depression would help the patient cope
more effectively with diabetes. Physicians
could include depression assessment and
treatment in diabetic care protocols as part
of self-management support.
A low level of literacy is another potential
barrier to active participation, and address-
ing health literacy in chronic illness has been
associated with better outcomes.21 Asking
the patient to repeat information that has
been given them is an easy way to identify
any misunderstanding.21 Additionally, giv-
ing patients clear instructions and informa-
tion about how to monitor symptoms, use
measurement tools, schedule appointments,
and take medications makes it much easier
for them to participate in setting goals and
planning their actions.
Physicians can further support patient self-
management by making changes in practice
systems. Group visits could be scheduled for
interested patients with comparable chronic
illnesses (e.g., diabetes, heart disease) so that
they can discuss self-managing their illnesses
with others who are in similar situations.22
The scheduling of 30- to 45-minute planned
individual visits would allow patients and
physicians time to address medical manage-
ment issues such as symptom control and
potential complications. This also would allow
time for setting goals, creating plans to reach
those goals, and solving the challenges of role
and emotional management.15 Office staff
or other health care professionals can assist
patients with planned visit tasks. Self-man-
agement support is most effective when it is
consistently available from all members of the
family practice.10 Disease management guide-
lines could be used as prompts for patient
reminders and to structure planned visits.
Systematic follow-up is another means
of providing patients with support. In one
controlled study,5 weekly phone calls from
a nurse manager and monthly calls from
a physician were shown to improve blood
sugar control and weight loss in patients
with diabetes. In another trial23 involv-
ing patients with diabetes, feedback from a
touch-screen computer assessment was used
to identify key barriers, which were then
checked at regular intervals; this was found
to increase the efficacy of dietary self-man-
agement. It also provides an example of how
technology can be used to support self-man-
agement of chronic conditions.
Simple time-saving devices, such as ensur-
ing laboratory values are available when
patients arrive, reminding patients with dia-
betes to remove footwear while they are
waiting for the physician, having self-man-
agement materials on hand, or having ready
access to Web-based resources also help
Family physicians can support patient self-
management by providing information
about community resources such as the local
health department, chamber of commerce,
and YMCA, as well as local chapters of societ-
ies such as the Arthritis Foundation and the
American Lung Association. Patients with
arthritis have reported improved pain con-
trol and mood through participation in pro-
grams emphasizing four efficacy-enhancing
strategies: mastery of skills through learning
and practice, modeling by inspirational role
leaders, encouraging participants to attempt
more than they are currently doing, and
reinterpretation of symptoms to distinguish
pain caused by disease from that caused
by therapeutic exercise.24 Many community
organizations offer exercise programs, self-
help groups, patient education classes, and
self-management programs. The physician
can serve as a conduit for directing patients
to these resources, and could make office
space available to community groups.
is most effective when it is
consistently available from
all members of the family
October 15, 2005 ◆ Volume 72, Number 8?
American Family Physician 1507
Self-management support tools are avail-
able to guide discussion between physician
and patient in such a way that the patient
determines his or her goal, identifies steps to
achieve the goal, identifies barriers to reaching
the goal, and plans for overcoming the barri-
ers, including obtaining needed resources.20
The Target Practice model (Figure 2)25,26
can be used to guide the goal-setting conver-
sation and lead the patient toward developing
a personal action plan. If the patient reports
Options for self-management of your chronic conditions
Circle all conditions that you manage: diabetes, asthma, hypertension,
arthritis, heart disease, others: _______________________________
• The circle includes a variety of self-management
skills … they ALL may be highly important to your health,
but you don’t need to do ALL of them ALL the time.
• If there is a topic that is more important to you,
add it to the circle.
• Nobody does all of these perfectly.
• It is best to work on one or two at a time.
• This is a partnership. You will not be pushed.
• You choose which one(s) you want to discuss today.
The steps outlined below give an interactive feedback loop
between physician and patient.
figure 2. Target practice: a self-management tool for physicians and their patients with chronic illness.
Adapted from “Supporting Patients to Self-manage Chronic Conditions,” a presentation by C. Davis, Institute for Healthcare Improvement, December 2003,
with information from reference 26.
Checking blood sugar
Eating: food choices,
time of day
Checking feetReferralsPhysical activity
Fatigue Taking medicineRegular visits
Relaxation and playUsing inhaler
advise: Provide the
requested by patient
ask: What do you
want to know about
ask: What are your concerns
about your condition(s)?
What do you want to happen in your
life regarding your condition(s)?
What would it take for that to happen?
What are the barriers?
ask: How confident are you in your
ability to carry out your action
plan, on a scale of zero to 10?
If confidence level is less than 7,
what would it take to get your
confidence rating to 7 or more?
Support: Follow up and
fine-tune action plan.
Inquire by phone or in
planned encounter about
challenges and success.
Repeat process for problem solving
and making new action plans.
select one topic from
assist: Clarify goals
and action plan,
using personal action
agree: Identify goals and
action plan to address
1508 American Family Physician
Volume 72, Number 8 ◆ October 15, 2005
a low confidence level in accomplishing the
action steps (i.e., less than 7 on a scale of
zero to 10, with 10 being extremely high con-
fidence and zero being extremely low), the
physician-as-partner works with the patient
to modify the plan until the patient has a
confidence level of 7 or higher.
The Personal Action Plan (Figure 3)27
helps patients with chronic illness to develop
a personal plan for learning a new behavior,
such as starting a program to increase their
physical activity. “Stoplight” tools, such as
the Diabetes Zones for Management guide
(Figure 4),28 divide various signs and symp-
toms into green, yellow, and red management
zones. Green indicates stability and good
control over the condition; yellow indicates
caution and suggests steps for regaining con-
trol; and red indicates a medical crisis that
requires a physician’s attention.
Tools such as these may be particularly
important when community resources are
limited. Additional guidelines and tools for
self-management are available at the Web site
of the Institute for Healthcare Improvement
Conditions/AllConditions/Tools) and the
Improving Chronic Illness Care Web site
Author disclosure: Nothing to disclose.
Members of various family medicine departments
develop articles for “Practical Therapeutics.” This
article is one in a series coordinated by the Department
of Family and Geriatric Medicine at the University of
figure 3. Personal action plan. Helping patients with chronic conditions to develop a plan for learning new behaviors.
Reprinted with permission from the Institute for Healthcare Improvement. Available online at http://www.ihi.org/IHI/Topics/ChronicConditions/Diabetes/Tools.
Personal action Plan
The change I want to make happen is: ____________________________
My goal for the next month is: ___________________________________
The specific steps I will take to achieve my goal are: (include what,
when, how, where, and how often)
The things that could make it difficult to achieve my goal include:
My plan for overcoming these challenges includes:
Support and resources I will need to achieve my goal include:
My confidence that I can achieve my goal is: (scale of zero to 10,
with zero being not confident at all and 10 being extremely
Review date: _____________________________________
MARY THOESEN COLEMAN, M.D., PH.D., is associate professor and vice chair
for clinical affairs in the Department of Family and Geriatric Medicine at the
University of Louisville, Ky. She also is associate dean of curriculum for aca-
demic affairs at the University of Louisville School of Medicine. Dr. Coleman
received her medical degree and doctoral degree in biochemistry from Ohio
State University, Columbus, Ohio, where she also completed a family medicine
KAREN S. NEWTON, R.D., M.P.H., is project director in the Department of Family
and Geriatric Medicine at the University of Louisville. A registered and licensed
dietitian, Ms. Newton is a graduate of San Diego State University, San Diego,
and received her master of public health degree in nutrition and health promo-
tion at Loma Linda University, Loma Linda, Calif.
Address correspondence to Mary Thoesen Coleman, M.D., Ph.D., 501 E.
Broadway, Suite 270, Med Center One Building, Louisville, KY 40292 (e-mail:
email@example.com). Reprints are not available from the authors.
October 15, 2005 ◆ Volume 72, Number 8?
American Family Physician 1509
Louisville School of Medicine, Louisville, Ky. Coordinator
of the series is James G. O’Brien, M.D.
1. Hoffman C, Rice D, Sung HY. Persons with chronic
conditions. Their prevalence and costs. JAMA
2. Wagner EH. Meeting the needs of chronically ill people.
3. Bodenheimer T, Wagner EH, Grumbach K. Improving
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JT, Assendelft WJ. Interventions to improve the man-
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figure 4. Diabetes zones for management: a stoplight tool.
NOTE: A1C levels given in percent; blood sugar levels given in mg per dL (150 mg per dL = 8.3 mmol per L; 200 mg per dL = 11.1 mmol per L; 210 mg per
dL = 11.7 mmol per L).
Adapted with permission from Alaska Area Diabetes Program. Available online at http://www.improvingchroniccare.org/tools/criticaltools.html.
• A1C level is less than 7
• Average blood sugar levels typically less than 150
• Most fasting blood sugar levels less than 150
• A1C between 7 and 9
• Average blood sugar level between 150 and 210
• Most fasting blood glucose levels less than 200
work closely with your health care team if you are
going into the yellOw zone.
• A1C level greater than 9
• Average blood sugar levels greater than 210
• Most fasting blood glucose levels greater than 200
call your physician if you are going into the Red zone.
green zone means:green zone: great control
yellow zone means:yellow zone: caution
Red zone means:Red zone: stop and think
• Your blood sugars are under control.
• Continue taking your medications as ordered.
• Continue routine blood glucose monitoring.
• Follow healthy eating habits.
• Keep all physician appointments.
• Your blood glucose levels may indicate that you need
to adjust your medications.
• Improve your eating habits.
• Increase your activity level.
call your physician if changes in your activity level
or eating habits do not decrease your fasting
blood glucose levels.
• You need to be evaluated by a physician.
• If you have a blood glucose level higher than _______ ,
follow these instructions: _____________________________
call your physician.
diabetes Zones for management
1510 American Family Physician Download full-text
Volume 72, Number 8 ◆ October 15, 2005
11. Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J.
Self-management approaches for people with chronic
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12. Rothman AA, Wagner EH. Chronic illness manage-
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17. Miller WR, Rollnick S. Motivational interviewing: pre-
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21. Schillinger D, Grumbach K, Piette J, Wang F, Osmond
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