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Health Promotion & Self-Management in Chronic Care: Community programs in the

United States and Thailand

Mary Anne Schr,rltz *

Clhanjar Suntavakomx*

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x AssistaDr profcssor. Calif'omia Srats Uni|crsity. Los Angelcs+*Assistant Profcssor. Naresuan Unj\.ersirl,. philsanulok. Thaiiand

Disease management has trecome anidentificd $ay to improvc health statLls and control ofchronrc jonJiti,,n, through ri,k stralrlicJrio.t. larg(rcd

n.rr\e ou reach. tcicmcdrcine. tclenursing. care

coordination and evidence-based i llness-uranagemcnt

fRob1. Korninski & loural (2ouq I. lmpro\ rrg oulcomcs

rvithincluonic disease has become a hcalth care systcnimpdative in the UDited States and thrcughout thc world.

In fact, aglobal goalibr the managementollhc chronic

dlseaseburden is to sustain indiviclual actions necessary

to increase the quality and years of a healthy lii.e(Institute ofMedicine, 20 I l ). A rargct i.orthis proposed

goat ls an additionaj 2oZ reduction in chronic disease

death rares annually by 2015 (WltO. 20l t). The

indicators for the mcasurement ofsuccess to$,ards this

goal are rhe number ofchronic disease dcaths averlc.l

and the numbcr ofhealthy iife ycars gaured.

To rhat cnd. rhe Chronic Care Modcl (CCM),

dc\,eioped by Wagner (199g), then. Wagncr ct al.(2001 ) provides an approach to rhe improvcmenl olhealth carc on many levels. The necessary elements

are the commrmity. thehealth systen, seif-management

support. delivery system design, decision suppon and

clinical infbrmation systems. Evidence_basco cnange

coDcepts ullder each elcment. in combination, ibster

productive intenctions betu,,een infolmed paticnts who

f@ lorrnut of NLrrsing and Health Sciences Vo 5 Specla lssue .,"*,;tro,r,ll

of empowering followers to find and usc resources'

fostering thc developmcnt of coping skills as well as

designing educational programs based on the bcst

availablc scientifi c cvidence of disease management

Further, the cmcial role of nursing in risk reduction

and the promotion of healthy bebavlors 1s also

commonly acknowledged (Moriyama et al ' 2009)'

Shrdies of the impoitance of self-managcment programs

in health promotion for a variety of chronic diseases

exists. These studies have identiltcd the vital function

of the generalist nurse in evidence-based program

design and care management in a many common and

costly conditions throughout the world' including

cercbrovascular diseasc (CVD) (Suntayakorn' C'

Somsak & Kanthapang, 2011), T2DM (Handlcy'

Shumway & Schillinger, 2008; Moriyama et al ' 2009)

Inflammatory Bowcl Disease (lBD) (Stansfield &

Robinson. 2008) and Congestive Heart Failue (CHF)

(Smeulden et al., 201 l).

Targeted outreach and program deslgn' as two

key functions nursjng fulfills in self-managed care' are

illustntcd in thc clinical scenarios bclow Two programs

oftargeted nurse outreach in community health' one in

rural Thailand and one outside of San Francisco' are

examined to illustrate how nurse-led self-care

managemcnt impacted self-care behavior and patrent

oulcomcs. Each is cliscussed, in turn' below'

Risk-RedLctiol Lnd SellMarlag-emenl irr

At-RskClientsirNodheln Thailand

In a quasi-experirncntal study aimed at

examining the effects of a self-care managcment

program on CVD isk aDd prevention of CVD within

an at-risk gror-rp ofresi<lens ofa rural l'illage in N orlhem

Thailand, Suntayakom, Tojampa, & Kanthapang

(2011) rr:poted that the self-managed goup (N=30)

mkc an activc par| it their care and providcrs with

resources and expertise. The CCM canbc appliedto a

variety of chronic illnesses, health care settlngs alrq

urget populatjons The bottom line is healthier paticnts'

more satisfied providers' and cost savings Within the

CCM, it is self-managemcnt suppolt thal is ofpafiicular

interest to nutsing given that nurses can provide care

that is holistic and continuous' not fiagmented or

episodic as is the casc in the current acute-carc model

for health care in the United States and many olher

counrles

The pupose ofthis paper is to discuss nulsing'

s role in promoting patient self-management and health

promotion processes within the contcxt of chronic

diseasc. The design and nursing care proccsses of a

self-managementprogram for ctfonic cerebrovascular

community health clients in a Norlhem Thailand villagc

is discussed. Similar care management practices are

identified in a San Francisco (United States) area public

health department in another common and costly

chronic and wlnerable population, lhose with type 2

diabetes (T2DM). A case for cvidcnce-based self-

carc management programs designcd and led by nurses

15 made.

Se.|aMLnagemenl and Chronic{are

Self-management, a theme within chronic carc'

was definedby Retlman (2004) as tbllows:training that

people with chlonic health conditions need to be able

ro deal $ilh taking medicines and mxintaining

therapeutic regimes, maintaining cveryday life such

as employmcnt and family, and dealing with the future'

including changing life plans and the frustrafon' anger

and depression (P. 2)

The role ofnursing repofied in studics of self-

managcd programs in chronic drsease tcnds to bc one

had significanlly better isk-reduction behavioN, lower

systolic blood pressure. lower body mass index and

lower diastolic blood pressue than their control-group

(N=30) counteryarts. Thc findings were attributed to

tbc sclf-managcmcnt stratcgics designed to equip the

residenls with a better understanding of self-

management and knowledgc and skills for self-

monitoring, self-evaluation and self-reinlbrccmcnt.

Taught to the expcrimental group in a one day

workshop by nurses and the researchers, the content

included the impodance of food selection, cxercise

and weight control as well as meditation. Hcalth

volunteers also attended and thcy wcre deployed to

visit clients every two weeks to motivatc them and

reinforce the impofiance of keeping records of thcir

healthy lifcstylcs. Clicnts followed for 12 weeks

reported sigrificant lifestylc changes in a questionnaire

designed by lhe investigators. The content of the

educational program was cvidence-derived.

Automatic TelephonqSelf-Management in

San Francisco Public Health

In a randomizcd controlled trial of self-

managcment support among dive$e clients with T2DM

in a safety-net system \rithin the Communib' Health

Network ofSan Francisco (California, United, States).

Handlcy, Shumway and Schillinger (2008) reported

the cost-ef}-ectiveness of an intervention program of

telcphone self-managemenr iupporl from nursing.

Specifically, the per patient cost estimate for

achievemcnt of a 107o increase in the proportion of

intervention paticnts mceting the exercisc guidelines

of the American Diabetes Association (ADA) rlas

$558. Based on self-reports of the duration and

frequency of exercise and the use of standard cost

estimate procedures, thc findings were athibuted to

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the addition of Automated Telephone Support

Managcmcnt (ATSM) with nursing advice (in addition

to ffcatmcnt as usual) for the experimental group

(N:l 12) versus the control group (N:-114) who

cxperienced or y teatment as usual.

The venue of ATSM (phone support) is

thought to be most useful when padicipants have a

range oflanguage dilferences and literacy levels and

or have geographic or mobility issucs with access to

carc. An obvious advantage is also thatwith the ATSM

comes the phone support of a nurse-provider which

has been reported to be a factor associatcd to patient

satisfaction (Pierrc.2000). The rcscarchcrs statcd that

because a considerable proportion ofcosts were fixed,

cost-utility and cost-cffcctiveness estimates would

likely be substantially improvcd in a scaled-upATSM

program.

Conclusion

As disease management shifu from incomplctc

scattered episodes of care to a mote comprehensive

approach such as CCM (Danccr & Courtney, 2010),

the role ofthe nulse in targeted outeach and evidence-

based progran design will be crucial. As new

interr'€ntions become available in tbe nursing carc of

patients $,ith chronic diseases suchas C\rD andT2DM

thc nursc will bc wcll-positioned to efl-ectivcly improve

the care of these patients through targeted outreach

and planned self-management program re-dcsign.

The multifaceted role ofthe nurse in chronic

care management is well documentedi expert, health

coach, teacher, facilitator and motivator. Yet self-

management is thought to be caried out in a iimited

way by patients and providers (Jobnston, Liddy & Ives,

201 l). As nurses and othcr providers fully realize the

impact that self-management can have on heahh

4 ) Journal of Nurs ng and Hea th Sciences Vol. 5 Special lssue January - Apr | 201 1

outcomes, disease outcomes and cost_savings to a

health care system, it is likely they will become more

engaged in those care management processes

inespective oftheir current plactice configwation ard

goals. In industrialized countries such as the United

States as well as indeveloping nations like Thailand, it

is hoped that a meaningful shift from the disease-based

and revolving-door approach in chronicity to self-

management in wlnerable populations ofpeople who

tend to have multiple chrcnic states will occur. Ifproviders focus on the engagement of consumer-

patients in critical elements oftheir care, a very positive

impact on specific indicators necessary to imprcvethe

health ofa nation should occur.

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