Chronic disease self-management (CDSM) programs
Chronic disease self-management (CDSM) programs support patients’ active management of their condition(s) in their daily life through education and behavioral interventions. Programs vary by specific disease but often focus on self-monitoring and medical management, decision making, or adoption and maintenance of health-promoting behaviors. Programs are usually delivered in-person and one-on-one in health care settings by health professionals but may be provided by nurses or lay individuals in community settings, in group settings1, and virtually through a computer, text messaging, or apps on mobile devices2. CDSM programs can also be used to manage multiple chronic conditions; features often include educational components, goal setting, peer support, and self-monitoring3.
What could this strategy improve?
Expected Benefits
Our evidence rating is based on the likelihood of achieving these outcomes:
Improved health outcomes
Increased healthy behaviors
Improved quality of life
Increased self-efficacy
Potential Benefits
Our evidence rating is not based on these outcomes, but these benefits may also be possible:
Improved mental health
Reduced hospital utilization
Improved chronic disease management
Improved care for chronic conditions
What does the research say about effectiveness?
There is strong evidence that chronic disease self-management (CDSM) programs improve health outcomes2, 4, 5, 6, 7, 8, 9, 10, increase healthy behaviors4, 10, 11, 12, 13, 14, 15, improve quality of life5, 12, 16, 17, 18, and increase self-efficacy for patients with various chronic conditions4, 5, 11, 12, 13, 17, 19. Additional evidence is needed to confirm effects for specific symptoms and conditions.
CDSM programs reduce HbA1c levels1, 2, 4, 20, 21 and improve systolic blood pressure in diabetic patients2, improve systolic21, 22 and diastolic blood pressure in patients with hypertension21, and improve diastolic blood pressure in patients with cardiovascular disease2. Programs also reduce the number of attacks in asthmatic patients22 and the frequency of symptoms, physical limitations, and depression for patients with stable angina7. Such programs may also improve osteoarthritis symptoms21, 23. Group-based CDSM programs can improve diet and weight management for diabetic patients and can increase medication adherence and self-efficacy1.
CDSM for patients with chronic obstructive pulmonary disease (COPD) has been shown to improve quality of life16, 18, particularly if it includes an action plan to recognize and treat exacerbation of symptoms16. CDSM can also reduce emergency room visits for COPD, especially if programs target mental health and symptom management18. Programs may reduce hospitalizations when used for specific conditions such as COPD6, 16, but do not appear to affect hospitalization rates overall11, 12.
Chronic disease self-management programs may improve patients’ communication with physicians10, 11. CDSM led by specially trained nurses in chronic care community-based programs can improve health outcomes among patients with diabetes or cardiovascular disease2. Theory-based CDSM programs have been shown to increase self-efficacy and diabetes knowledge and improve HbA1C among patients with diabetes4.
Computer-based self-management programs delivered in health care settings can improve patient health behaviors and clinical outcomes14. Web-based CDSM programs can reduce depression, anxiety, and fatigue, and improve overall quality of life for individuals living with cancer as a chronic disease24. Computer and mobile-based interventions may increase quality of life and level of activity for people with COPD in the short-term25. Web-based CDSM appears to improve conditions such as asthma, recurrent pain, and obesity among youth26 and increase self-efficacy and disease management activities among older adults19. Web-based CDSM also appears to improve health behaviors and clinical and psychological outcomes in patients with diabetes13. Programs that use text messaging increase patients’ appointment attendance, antiretroviral therapy adherence, and short-term smoking quit rates15. International studies suggest mobile health (mHealth) apps used for CDSM show potential to improve health outcomes, symptom management20, and medication adherence27.
CDSM programs have been shown to benefit various populations, including minority groups in the short-term9 and adults with serious mental illness8. CDSM has also been shown to improve activities of daily living (ADL) for community-dwelling older adults with chronic conditions28. Children and adolescents can also engage in age-appropriate self-management of their chronic diseases with the support of family, health care providers, and peers; involving youth in developing the intervention and including technology can contribute to successful self-management behaviors29. Additional evidence is needed to determine effects for chronically ill patients with low incomes30.
Men, who are often less likely to participate in CDSM programs, appear to be more likely to complete CDSM programs if they are older, non-white, or live in rural areas31.
How could this strategy advance health equity? This strategy is rated inconclusive impact on disparities.
It is unclear what impact chronic disease self-management (CDSM) programs may have on disparities in chronic diseases.
People with one or more chronic diseases are at greater risk for disability, death, poor functional status, unnecessary hospitalizations, and many other challenges36. Individuals from minoritized racial backgrounds37, from rural areas38, and those with low incomes are disproportionately more likely to have one or more chronic disease39. Patients who are racial and ethnic minorities are almost twice as likely to be affected by major chronic diseases such as asthma, diabetes, hypertension, obesity, and mental illness compared to patients who are white37. Similar disparities exist between patients with different incomes: for example, diabetes rates are twice as high among adults with lower incomes than those with higher incomes39. Rural residents, particularly those from minoritized backgrounds, are more likely to experience chronic diseases and have higher mortality rates than those in urban areas40. People living in disadvantaged areas (i.e., with lower levels of safety, walkability, access to health care, nutritious foods, recreation, and higher levels of stress) are at higher risk for negative health outcomes, including hypertension and diabetes, and these communities are disproportionately Black. Hypertension and diabetes are less likely to be adequately managed in Black patients, regardless of income level40.
A North Carolina-based study suggests engaging workers receiving lower-to-middle wages in the Chronic Disease Self-Management Program (CDSMP) appears to increase the participation of populations from minoritized racial and ethnic backgrounds, who are also more likely to complete the program than white individuals41. CDSM programs can improve health outcomes in rural and under-resourced areas1, among populations from diverse racial and ethnic backgrounds1, individuals with low incomes42, individuals who are differently abled43, and members of the deaf community44.
Studies among Chinese Americans suggest programs which are culturally tailored can improve health outcomes, increase knowledge regarding the chronic condition, and improve participants’ self-efficacy5.
What is the relevant historical background?
The Federal Housing Administration’s redlining practices entrenched racial residential segregation in the U.S. and resulted in fewer health care facilities, resources, and funding in urban areas with largely Black populations45, 46. Past residential redlining and present-day disparities in access to health care are associated with delays in disease diagnosis and treatment of health conditions, fewer preventive health visits, shortages of behavioral health clinicians, and larger Medicaid or uninsured populations in neighborhoods with residents that are primarily Black and low income45. Formerly redlined neighborhoods are more likely to be near man-made environmental hazards producing pollution or toxins and have older homes in poor condition containing health hazards such as lead paint and mold47, and residents continue to experience worse health outcomes, including chronic diseases like diabetes46. Rural areas lack adequate access to physicians; approximately 20% of the U.S. population resides in rural areas, but only 10% of physicians provide care there48.
Chronic diseases have increased in prevalence over the last century as public health and modern medicine became increasingly effective in preventing and treating communicable diseases and are now the leading causes of death. Unlike diseases caused by single pathogens, chronic diseases are often the result of multiple factors accumulating over time, with aspects of the neighborhoods and communities that individuals live in harming them by restricting their opportunities for healthy living49. The chronic disease management (CDM) model emerged in the 1990s because of the increasing prevalence and complexity of treating patients with chronic illnesses50.
Equity Considerations
- What are the disparities in chronic disease prevalence in your community? Which groups are most affected?
- What resources are available for chronic disease management? Are there programs for chronic disease self-management? Are certain groups less able to access the care, services, and programs available?
- What are the barriers to offering and accessing high quality linguistically and culturally appropriate chronic disease self-management programs? Are programs available or modifiable according to participants’ health literacy status?
- How can chronic disease self-management programs be delivered more equitably? What partnership opportunities exist in your community to increase access to these programs? Are there opportunities to establish peer support within programs while promoting behavior change and self-management skills?
Implementation Examples
There are many types of chronic disease self-management (CDSM) programs implemented across the United States. The National Council on Aging provides a list of CDSM programs specific to conditions like arthritis, asthma, chronic obstructive pulmonary disease (COPD), and diabetes32 while the Centers for Disease Control and Prevention (CDC) offers self-management workshops and toolkits on conditions such as arthritis and diabetes33, 34. The Self-Management Resource Center maintains the Chronic Disease Self-Management Program (CDSMP), created by Stanford, which is widely used and available in English and Spanish35.
Implementation Resources
‡ Resources with a focus on equity.
SMRC-CDSMP - Self-Management Resource Center (SMRC). Chronic disease self-management program (CDSMP).
CDSMP-Toolkit - National Council on Aging. Chronic disease self-management program (CDSMP): A toolkit for hospitals. 2012.
NCOA-CDSM - National Council on Aging (NCOA). Chronic disease self-management (CDSM) programs.
Held 2019‡ - Held S, Hallett J, Schure M, et al. Improving chronic illness self-management with the Apsáalooke Nation: Development of the Báa nnilah program. Social Science and Medicine. 2019;242:112583.
CDC-Arthritis - Centers for Disease Control and Prevention (CDC). Arthritis: Encouraging self-management.
CDC-DSMES - Centers for Disease Control and Prevention (CDC). Diabetes Self-Management Education and Support (DSMES) Toolkit.
Footnotes
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1 Cutler 2018 - Cutler S, Craford P, Engleking R. Effectiveness of group self-management interventions for persons with chronic conditions: A systematic review. MEDSURG Nursing. 2018;27(6):359-367.
2 Massimi 2017 - Massimi A, De Vito C, Brufola I, et al. Are community-based nurse-led self-management support interventions effective in chronic patients? Results of a systematic review and meta-analysis. PLOS ONE. 2017;12(3):e0173617.
3 Miller 2020 - Miller JJ, Pozehl BJ, Alonso W, Schmaderer M, Eisenhauer C. Intervention components targeting self-management in individuals with multiple chronic conditions: An integrative review. Western Journal of Nursing Research. 2020;42(11):948-962.
4 Zhao 2017 - Zhao FF, Suhonen R, Koskinen S, Leino-Kilpi H. Theory-based self-management educational interventions on patients with type 2 diabetes: A systematic review and meta-analysis of randomized controlled trials. Journal of Advanced Nursing. 2017;73(4):812-833.
5 Huang 2020 - Huang Y-C, Garcia AA. Culturally-tailored interventions for chronic disease self-management among Chinese Americans: A systematic review. Ethnicity and Health. 2020;25(3):465-484.
6 Cochrane-Zwerink 2014 - Zwerink M, Brusse-Keizer M, van der Valk PDLPM, et al. Self management for patients with chronic obstructive pulmonary disease: Review. Cochrane Database of Systematic Reviews. 2014;(3):CD002990.
7 McGillion 2014 - McGillon M, O'Keefe-McCarthy S, Carroll SL, et al. Impact of self-management interventions on stable angina symptoms and health-related quality of life: A meta-analysis. BMC Cardiovascular Disorders. 2014;14:1-10.
8 Siantz 2014 - Siantz E, Aranda MP. Chronic disease self-management interventions for adults with serious mental illness: A systematic review of the literature. General Hospital Psychiatry. 2014;36(3):233-244.
9 Sidhu 2014 - Sidhu MS, Gale NK, Gill P, et al. A systematic review of lay-led group-based self-management interventions for minority ethnic populations diagnosed with long-term conditions in high income countries. Diversity and Equality in Health and Care. 2014;11(3-4):225-236.
10 Brady 2013 - Brady TJ, Murphy L, O’Colmain BJ, et al. A meta-analysis of health status, health behaviors, and health care utilization outcomes of the chronic disease self-management program. Preventing Chronic Disease. 2013;10:1-14.
11 Franek 2013 - Franek J. Self-management support interventions for persons with chronic disease: An evidence-based analysis. Ontario Health Technology Assessment Series. 2013;13(9):1-60.
12 Cochrane-Foster 2007 - Foster G, Taylor SJC, Eldridge S, Ramsay J, Griffiths CJ. Self-management education programmes by lay leaders for people with chronic conditions. Cochrane Database of Systematic Reviews. 2007;(4):CD005108.
13 van Vugt 2013 - van Vugt M, de Wit M, Cleijne WHJJ, Snoek FJ. Use of behavioral change techniques in web-based self-management programs for type 2 diabetes patients: Systematic review. Journal of Medical Internet Research. 2013;15(12):e279.
14 McDermott 2013 - McDermott MS, While AE. Maximizing the healthcare environment: A systematic review exploring the potential of computer technology to promote self-management of chronic illness in healthcare settings. Patient Education and Counseling. 2013;92(1):13-22.
15 Jones 2014 - Jones KR, Lekhak N, Kaewluang N. Using mobile phones and short message service to deliver self-management interventions for chronic conditions: A meta-review. Worldviews on Evidence-Based Nursing. 2014;11(2):81-88.
16 Cochrane-Lenferink 2017 - Lenferink A, Brusse-Keizer M, van der Valk PDLPM, et al. Self-management interventions including action plans for exacerbations versus usual care in patients with chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews. 2017;(8):CD011682.
17 Cochrane-Fryer 2016 - Fryer CE, Luker JA, McDonnell MN, Hillier SL. Self management programmes for quality of life in people with stroke. Cochrane Database of Systematic Reviews. 2016;(8):CD010442.
18 Newham 2017 - Newham JJ, Presseau J, Heslop-Marshall K, et al. Features of self-management interventions for people with COPD associated with improved health-related quality of life and reduced emergency department visits: A systematic review and meta-analysis. International Journal of Chronic Obstructive Pulmonary Disease. 2017;12:1705-1720.
19 Stellefson 2013a - Stellefson M, Chaney B, Barry AE, et al. Web 2.0 chronic disease self-management for older adults: a systematic review. Journal of Medical Internet Research. 2013;15(2):e35.
20 Whitehead 2016 - Whitehead L, Seaton P. The effectiveness of self-management mobile phone and tablet apps in long-term condition management: A systematic review. Journal of Medical Internet Research. 2016;18(5):e97.
21 Chodosh 2005 - Chodosh J, Morton SC, Mojica W, et al. Meta-analysis: Chronic disease self-management programs for older adults. Annals of Internal Medicine. 2005;143(6):427-438.
22 Warsi 2004 - Warsi A, Wang PS, LaValley MP, Avorn J, Solomon DH. Self-management education programs in chronic disease: A systematic review and methodological critique of the literature. Archives of Internal Medicine. 2004;164(5):1641-1649.
23 Cochrane-Kroon 2014 - Kroon FPB, van der Burg LRA, Buchbinder R, et al. Self-management education programmes for osteoarthritis. Cochrane Database of Systematic Reviews. 2014;1:CD008953.
24 Kim 2015a - Kim AR, Park HA. Web-based self-management support interventions for cancer survivors: A systematic review and meta-analyses. Studies in Health Technology and Informatics. 2015;216:142-147.
25 Cochrane-McCabe 2017 - McCabe C, McCann M, Brady AM. Computer and mobile technology interventions for self-management in chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews. 2017;(5):CD011425.
26 Stinson 2009 - Stinson J, Wilson R, Gill N, Yamada J, Holt J. A systematic review of internet-based self-management interventions for youth with health conditions. Journal of Pediatric Psychology. 2009;34(5):495-510.
27 Lee 2018f - Lee J-A, Choi M, Lee SA, Jiang N. Effective behavioral intervention strategies using mobile health applications for chronic disease management: A systematic review. BMC Medical Informatics and Decision Making. 2018;18:12.
28 van het Bolscher-Niehuis 2016 - van het Bolscher-Niehuis MJT, den Ouden MEM, de Vocht HM, Francke AL. Effects of self-management support programmes on activities of daily living of older adults: A systematic review. International Journal of Nursing Studies. 2016;61:230-247.
29 Camp-Spivey 2022 - Camp-Spivey LJ, Logan A, Nichols M. Theoretical and contextual considerations for self-management strategies of children and adolescents with chronic diseases: An integrative review. Journal of Child Health Care. 2022;26(2):242-261.
30 Van Hecke 2017 - Van Hecke A, Heinen M, Fernández-Ortega P, et al. Systematic literature review on effectiveness of self-management support interventions in patients with chronic conditions and low socio-economic status. Journal of Advanced Nursing. 2017;73(4):775-793.
31 Smith 2018a - Smith ML, Bergeron CD, Ahn SN, et al. Engaging the underrepresented sex: Male participation in Chronic Disease Self-Management Education (CDSME) programs. American Journal of Men’s Health. 2018;12(4):935-943.
32 NCOA-CDSM - National Council on Aging (NCOA). Chronic disease self-management (CDSM) programs.
33 CDC-Arthritis - Centers for Disease Control and Prevention (CDC). Arthritis: Encouraging self-management.
34 CDC-DSMES - Centers for Disease Control and Prevention (CDC). Diabetes Self-Management Education and Support (DSMES) Toolkit.
35 SMRC-CDSMP - Self-Management Resource Center (SMRC). Chronic disease self-management program (CDSMP).
36 Bleich 2015 - Bleich SN, Sherrod C, Chiang A, et al. Systematic review of programs treating high-need and high-cost people with multiple chronic diseases or disabilities in the United States, 2008–2014. Preventing Chronic Disease. 2015;12:150275.
37 Price 2013 - Price JH, Khubchandani J, McKinney M, Braun R. Racial/ethnic disparities in chronic diseases of youths and access to health care in the United States. BioMed Research International. 2013:787616.
38 RHIhub-Chronic Disease - Rural Health Information Hub (RHIhub). Chronic disease in rural America.
39 Eyler 2019 - Eyler AA, Valko CA, Marti M, et al. Adjusting the equity lens: Gaps in addressing health equity in state chronic disease prevention. Health Equity. 2019;3(1):86-91.
40 Durfey 2019 - Durfey SNM, Kind AJH, Buckingham WR, DuGoff EH, Trivedi AN. Neighborhood disadvantage and chronic disease management. Health Services Research. 2019;54:206-216.
41 Kneipp 2019 - Kneipp SM, Horrell L, Gonzales C, et al. Participation of lower-to-middle wage workers in a study of Chronic Disease Self-Management Program (CDSMP) effectiveness: Implications for reducing chronic disease burden among racial and ethnic minority populations. Public Health Nursing. 2019;36(5):591-602.
42 Turner 2018a - Turner BJ, Liang Y, Simmonds MJ, et al. Randomized trial of chronic pain self-management program in the community or clinic for low-income primary care patients. Journal of General Internal Medicine. 2018;33:668-677.
43 Zengul 2023 - Zengul A, Evans E, Cherrington A, Mehta T, Thirumalai M. Self-management interventions for people with physical disabilities who have chronic conditions: A scoping review. Technology and Disability. 2023;35(2):79-130.
44 Havercamp 2020 - Havercamp SM, Gjessing R, Whalen Smith CN. Chronic Disease Self-Management Program in American Sign Language: Evaluation and recommendations. Health Promotion Practice. 2020;21(2):259-267.
45 Lee 2023 - Lee EK, Donley G, Ciesielski TH, Freedman DA, Cole MB. Spatial availability of federally qualified health centers and disparities in health services utilization in medically underserved areas. Social Science and Medicine. 2023;328:116009.
46 Lee 2022c - Lee EK, Donley G, Ciesielski TH, et al. Health outcomes in redlined versus non-redlined neighborhoods: A systematic review and meta-analysis. Social Science and Medicine. 2022;294:114696.
47 Braveman 2022 - Braveman PA, Arkin E, Proctor D, Kauh T, Holm N. Systemic and structural racism: Definitions, examples, health damages, and approaches to dismantling. Health Affairs. 2022;41(2):171-178.
48 Arredondo 2023 - Arredondo K, Touchett HN, Khan S, Vincenti M, Watts BV. Current programs and incentives to overcome rural physician shortages in the United States: A narrative review. Journal of General Internal Medicine. 2023;38:916-922.
49 Hong 2019b - Hong Y-C. Chapter 2: The age of chronic and late chronic diseases: A new view of diseases. In: The Changing Era of Diseases. Cambridge: Academic Press; 2019:35-68.
50 Wagner 1998 - Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1(1):2-4.
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