Self-management is also an integral part of the Chronic Care Model, developed by Ed Wagner, founder and director of the MacColl Institute for Healthcare Innovation and senior investigator at the Group Health Research Institute, Seattle.
The Chronic Care Model's approach involves the community, an empowered patient and a proactive, physician-led clinical team to provide safe, timely, evidence-based care, says Eric Larson, executive director of the institute and senior researcher. In addition to disease self-management, the model also emphasizes the need for clinical information systems, decision support and delivery-system design.
“The Chronic Care Model is an idealized way to provide primary care, and the medical home, although the concept certainly existed before, has become a way to realize the model and put it into practice,” Larson says.
Lack of reimbursement is not the only obstacle, according to Judith Schaefer, research associate at the Improving Chronic Illness Care program at the Robert Wood Johnson Foundation. Helping patients to set their own goals means taking into account what is important to them in a way that is respectful and free of judgment and that is not always easy for clinicians, she says. Patients often show up in primary-care offices feeling defensive and ashamed of their lack of progress, Bodenheimer says. Action plans are one way to suggest they make very small changes so that they are more likely to see positive results. Small successes breed more success, he says, because they build up patients' confidence and provide momentum. For instance, he says, telling a person who has diabetes and drinks 12 sodas a day to quit entirely would likely backfire. Instead he says: “Is there anything you could do about your soda drinking that might help your diabetes?”
“We do a lot of work with small amounts of exercise, smaller portions and medication adherence,” Bodenheimer says. “Sometimes we say things like, ‘If you can't take these eight medications, how many can you take?' That drives physicians crazy, but we need to focus on small changes and putting the patient in control.”
Self-management is also a key determinant of patient safety in the ambulatory setting, according to Robert Wachter, professor and chief of hospital medicine at UCSF and author of several books about patient safety. In a 2006 editorial in the Annals of Internal Medicine, Wachter highlighted several differences between patient safety in the hospital and in physicians' offices. The biggest difference, he said, was in the role of the patient.
“When a patient is in the hospital, we know where they are and we have control,” Wachter says. “There is some patient engagement, but ultimately the burden is on providers. In the ambulatory setting, the engagement of the patient is much more important. They can improve upon and also contribute to errors.”
Additionally, while hospitals have specialized personnel including chief information officers and infection-prevention specialists with whom to tackle safety concerns, physician practices are much more limited in their choices, Wachter says.
And for people with multiple chronic illnesses who are prescribed a complicated regimen of medications, the potential for adverse events is significant, says Urmimala Sarkar, assistant professor of medicine at UCSF.
“For patients who have multiple chronic diseases, the situation is much more complex,” Sarkar says. “If someone takes too much of one of their medications, but has reduced kidney function because of another health condition, that mistake could easily land them in the emergency room.”
Future success in providing safe and effective primary care will depend heavily on whether there is a system in place that offers incentives for patient education, says Wachter, who refers to pilot sites such as Greenhouse Internists as a “laboratory for understanding primary care.”
“These pilot programs are essential because they show us how successful medical homes can be,” Wachter says. “The truth is that medical homes will be too expensive for the system, as it is set up now. There has to be a way to capture payment.”