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Module 2: Self-Management Support (SMS)

The systematic provision of education and supportive interventions to increase skills and confidence of persons living with multiple chronic conditions (PLWMCC) in managing their health problems, including regular assessment of progress and problems, and problem-solving support1,2.

Making the Case for Self-Management Support (SMS) for Persons Living With Multiple Chronic Conditions (PLWMCC)

The purpose of self-management support (SMS) is to empower PLWMCC to manage their multiple chronic conditions (MCC) and take an active role in their own treatment. SMS includes active engagement of PLWMCC and their families and caregivers in disease management, proactive communication regarding their goals and action plans, and seeking assistance and support during exacerbations of their chronic conditions and/or any acute illnesses.

Chronic illness affects PLWMCC physically, socially and emotionally. In order to address these complex needs, practitioners and interprofessional healthcare teams need to take a holistic approach3, 4 when working with PLWMCC and their families and caregivers. The loss of prior life roles and the need to define new roles congruent with changing capacity add to the challenge of coping with MCC. Goal setting, action planning and problem solving, the core activities of SMS, can build confidence in managing one’s MCC. Effective SMS can improve health outcomes5 and quality of life6-9, and reduce depression10, healthcare utilization11, and mortality12.

PLWMCC experience challenges when managing multiple treatment regimens, changing health and lifestyle behaviors, and interacting with the healthcare delivery system. Many barriers impact PLWMCC’s self-management and decision-making abilities. Interactions between MCC make healthcare management more challenging15,16. In addition, individual beliefs, preferences and attitudes can influence the PLWMCC's decisions regarding their care13,14. With reduced physical, mental and social function or insufficient time and resources, PLWMCC may have reduced capacities to manage their conditions. PLWMCC may express frustration in dealing with numerous information sources and medications. Difficulties interacting with providers and healthcare systems are additional sources of frustration17. PLWMCC may have difficulty separating, comprehending, and using information about each condition18. Families and caregivers can be also negatively affected. For example, spouses of PLWMCC with poorer self-management skills and greater burden of illness show higher levels of stress19.

Interprofessional healthcare teams can have a positive influence on the behavior choices of PLWMCC. Interprofessional teams can help by discussing healthcare priorities with PLWMCC and their families and caregivers that inform self-management activities. These interactions can be effective in helping PLWMCC manage their complex care.20 Practitioners and interprofessional teams should collaborate with PLWMCC to identify goals, develop treatment plans and assist with problem solving. PLWMCC benefit from shared decision making with their practitioners; thereby, maximizing their health outcomes, function, and quality of life.

PLWMCC lessen the burden of treatment by using a variety of personal, social and healthcare resources. Assessing contextual factors like family supports, transportation availability and insurance status can help healthcare providers understand how PLWMCC fit complex self-care into their daily lives. The implementation of SMS and counseling can help PLWMCC set specific goals and help practitioners coordinate their care and arrange follow up contacts23. Interventions that lessen the burden of treatment for PLWMCC include creating a self-care routine achieved through action plans, and focusing on life priorities, social support and beneficial relationships with providers24.

Learning Objectives by Competency

Competencies and associated learning objectives are presented below for use by educators. The competencies apply to a wide variety of health professions students, faculty, and practitioners including physicians, nurses, psychologists, psychiatrists, dentists, pharmacists, social workers, allied health professionals, care coordinators, as well as interprofessional teams. These competencies apply across the educational continuum, and can be discipline specific or interprofessional. Examples of learning objectives are provided below. Educators may tailor objectives for a specific healthcare discipline and for a specific phase of education.

SMS 1. Support PLWMCC, their families and caregivers in setting goals, developing action plans, and continuously re-evaluating and revising them as needed.

Learning Objectives 

1. Collaboratively set healthcare goals with PLWMCC and their families and caregivers.

2. Continuously review and revise action plans for PLWMCC at each office visit.



SMS 2. Assist PLWMCC in identifying and evaluating information for appropriateness to inform their plans of care.

Learning Objectives 

1. Identify new appropriate sources of information for PLWMCC.

2. Establish and share criteria with PLWMCC for assessing new resources that might be used in plans of care.



SMS 3. Assist PLWMCC to link to appropriate community-based resources to support healthy behaviors and learn self-management techniques.

Learning Objectives 

1. Assess the appropriateness of community-based resources available to PLWMCC.

2. Establish working relationships with individuals at community-based organizations to facilitate referrals for PLWMCC.

3. Confirm that PLWMCC have accessed and understand recommended community-based resources that support behavior change(s) targeted in the action plan.



SMS 4. Use skill building and problem-solving strategies to support PLWMCC, their families and caregivers in managing MCC by adopting and maintaining health self-management behaviors, and in overcoming barriers to quality of life preferences.

Learning Objectives 

1. Share strategies with caregivers of PLWMCC for managing caregiver stress.

2. Demonstrate to PLWMCC how to solve an identified problem in managing their chronic illnesses.

3. Employ an incremental approach to develop the skills of PLWMCC in a specific technique or tool to manage MCC (e.g., blood sugar monitoring, responding to symptoms).



SMS 5. Discuss with PLWMCC and their families and caregivers how emotional responses to illness and mental health disorders may affect their ability to manage MCC.

Learning Objectives 

1. Elicit PLWMCC’s emotional and psychological responses to their illnesses.

2. Produce, in collaboration with PLWMCC and caregivers, a care plan that includes a mental health component.



SMS 6. Incorporate evidence-based behavior management strategies, such as peer leadership and coaching, to support PLWMCC engagement in managing MCC.

Learning Objectives

1. Produce, in collaboration with PLWMCC and their caregivers, a care plan that includes the use of a health coach.

2. Provide PLWMCC with a list of community-based resources that use peer leadership.



Selected Curricular Resources

The following is a list of curricular resources that address components of Self-Management Support (SMS). Links to each resource are provided (Note: Summaries for each resource will pop up when user clicks on resource name. The summaries will not be text on the page). Additional resources can be found in the MCC Education and Training Repository with live links.



1. Corrigan, J. M., & Adams, K. (Eds.). (2003). Priority Areas for National Action:: Transforming Health Care Quality.: National Academies Press.

2. Chassin, M. R., & Loeb, J. M. (2011). The ongoing quality improvement journey: next stop, high reliability. Health Aff (Millwood), 30 (4), 559-568.

3. O'Brien, R., Wyke, S., Guthrie, B., Watt, G., & Mercer, S. (2011). An 'endless struggle': a qualitative study of general practitioners' and practice nurses' experiences of managing multimorbidity in socio-economically deprived areas of Scotland. Chronic Illn, 7(1), 45-59.

4. Fortin, M., Hudon, C., Bayliss, E. A., Soubhi, H., & Lapointe, L. (2007). Caring for body and soul: the importance of recognizing and managing psychological distress in persons with multimorbidity. Int J Psychiatry Med, 37(1), 1-9.

5. Hibbard, J. H., Greene, J., Shi, Y., Mittler, J., & Scanlon, D. (2015). Taking the Long View: How Well Do Patient Activation Scores Predict Outcomes Four Years Later? Med Care Res Rev.

6. Katon, W. J., Rutter, C., Simon, G., Lin, E. H., Ludman, E., Ciechanowski, P., Kinder, L., Young, B., & Von Korff, M. (2005). The association of comorbid depression with mortality in patients with type 2 diabetes. Diabetes Care, 28(11), 2668-2672.

7. Ritter, P. L., Ory, M. G., Laurent, D. D., & Lorig, K. (2014). Effects of chronic disease self-management programs for participants with higher depression scores: secondary analyses of an on-line and a small-group program. Transl Behav Med, 4(4), 398-406.

8. Harrison, M., Reeves, D., Harkness, E., Valderas, J., Kennedy, A., Rogers, A., Hann, M., & Bower, P. (2012). A secondary analysis of the moderating effects of depression and multimorbidity on the effectiveness of a chronic disease self-management programme. Patient Educ Couns, 87(1), 67-73.

9. Chodosh, J., Morton, S. C., Mojica, W., Maglione, M., Suttorp, M. J., Hilton, L., Rhodes, S., & Shekelle, P. (2005). Meta-analysis: chronic disease self-management programs for older adults. Ann Intern Med, 143(6), 427-438.

10. Coventry, P., Lovell, K., Dickens, C., Bower, P., Chew-Graham, C., McElvenny, D., Hann, M., Cherrington, A., Garrett, C., Gibbons, C.J., Baguley, C., Roughley, K., Adeyemi, I., Reeves, D., Waheed, W., & Gask, L. (2015). Integrated primary care for patients with mental and physical multimorbidity: cluster randomised controlled trial of collaborative care for patients with depression comorbid with diabetes or cardiovascular disease. BMJ, 350.

11. Panagioti, M., Richardson, G., Murray, E., Rogers, A., Kennedy, A., Newman, S., Small, N., & Bower, P. (2014). Reducing Care Utilisation through Self-management Interventions (RECURSIVE): a systematic review and meta-analysis. Health Services and Delivery Research, No. 2.54.

12. Ryan, R., Santesso, N., Lowe, D., Hill, S., Grimshaw, J., Prictor, M., Kaufman, C., Cowie, G., & Taylor, M. (2014). Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews. Cochrane Database Syst Rev, 4, CD007768.

13. Bratzke, L. C., Muehrer, R. J., Kehl, K. A., Lee, K. S., Ward, E. C., & Kwekkeboom, K. L. (2014). Self-management priority setting and decision-making in adults with multimorbidity: A narrative review of literature. Int J Nurs Stud.

14. Morales-Asencio, J. M., Martin-Santos, F. J., Kaknani, S., Morilla-Herrera, J. C., Cuevas Fernandez-Gallego, M., Garcia-Mayor, S., Leon-Campos, A., & Morales-Gil, I. M. (2014). Living with chronicity and complexity: Lessons for redesigning case management from patients' life stories - A qualitative study. J Eval Clin Pract.

15. Janevic, M. R., Ellis, K. R., Sanders, G. M., Nelson, B. W., & Clark, N. M. (2014). Self-management of multiple chronic conditions among African American women with asthma: a qualitative study. J Asthma, 51(3), 243-252.

16. Coventry, P. A., Fisher, L., Kenning, C., Bee, P., & Bower, P. (2014). Capacity, responsibility, and motivation: a critical qualitative evaluation of patient and practitioner views about barriers to self-management in people with multimorbidity. BMC Health Serv Res, 14(1), 536.

17. Corser, W., & Dontje, K. (2011). Self-management perspectives of heavily comorbid primary care adults. Prof Case Manag, 16(1), 6-15.

18. Fix, G. M., Cohn, E. S., Solomon, J. L., Cortes, D. E., Mueller, N., Kressin, N. R., Borzecki, A., Katz, L. A., & Bokhour, B. G. (2014). The role of comorbidities in patients' hypertension self-management. Chronic Illn, 10(2), 81-92.

19. Masters, S., Oliver-Baxter, J., Barton, C., Summers, M., Howard, S., Roeger, L., & Reed, R. (2013). Programmes to support chronic disease self-management: should we be concerned about the impact on spouses? Health Soc Care Community, 21(3), 315-326.

20. Berry-Millett, R., & Bodenheimer, T. S. (2009). Care management of patients with complex health care needs. Synth Proj Res Synth Rep (19).

21. Mishra, S. I., Gioia, D., Childress, S., Barnet, B., & Webster, R. L. (2011). Adherence to medication regimens among low-income patients with multiple comorbid chronic conditions. Health Soc Work, 36(4), 249-258.

22. Morris, R. L., Sanders, C., Kennedy, A. P., & Rogers, A. (2011). Shifting priorities in multimorbidity: a longitudinal qualitative study of patient's prioritization of multiple conditions. Chronic Illn, 7(2), 147-161.

23. Petersen, J. J., Paulitsch, M. A., Mergenthal, K., Gensichen, J., Hansen, H., Weyerer, S., Riedel-Heller, S. G., Fuchs, A., Maier, W., Bickel, H., Konig, H. H., Wiese, B., van den Bussche, H., Scherer, M., & Dahlhaus, A. (2014). Implementation of chronic illness care in German primary care practices--how do multimorbid older patients view routine care? A cross-sectional study using multilevel hierarchical modeling. BMC Health Serv Res, 14, 336.

24. Ridgeway, J. L., Egginton, J. S., Tiedje, K., Linzer, M., Boehm, D., Poplau, S., de Oliveira, D. R., Odell, L., Montori, V. M., & Eton, D. T. (2014). Factors that lessen the burden of treatment in complex patients with chronic conditions: a qualitative study. Patient Prefer Adherence, 8, 339-351.

25. Bayliss, E. A., Ellis, J. L., & Steiner, J. F. (2007). Barriers to self-management and quality-of-life outcomes in seniors with multimorbidities. Ann Fam Med, 5(5), 395-402.

26. Walters, J. A., Courtney-Pratt, H., Cameron-Tucker, H., Nelson, M., Robinson, A., Scott, J., Turner, P., Walters, E. H., & Wood-Baker, R. (2012). Engaging general practice nurses in chronic disease self-management support in Australia: insights from a controlled trial in chronic obstructive pulmonary disease. Aust J Prim Health, 18(1), 74-79.

27. Ory, M. G., Ahn, S., Jiang, L., Smith, M. L., Ritter, P. L., Whitelaw, N., & Lorig, K. (2013). Successes of a national study of the Chronic Disease Self-Management Program: meeting the triple aim of health care reform. Med Care, 51(11), 992-998.

28. Bodenheimer, T., & Handley, M. A. (2009). Goal-setting for behavior change in primary care: an exploration and status report. Patient Educ Couns, 76(2), 174-180.

29. Schaefer, J., Miller, D., Goldstein, M., & Simmons, L. (2009). Partnering in self-management support: A toolkit for clinicians. Cambridge, MA: Institute for Healthcare Improvement.

30. Lorig, K., Laurent, D. D., Plant, K., Krishnan, E., & Ritter, P. L. (2014). The components of action planning and their associations with behavior and health outcomes. Chronic Illn, 10(1), 50-59.

31. Bodenheimer, T. (2008). Training Curriculum for Health Coaches.

32. Small, N., Blickem, C., Blakeman, T., Panagioti, M., Chew-Graham, C. A., & Bower, P. (2013). Telephone based self-management support by 'lay health workers' and 'peer support workers' to prevent and manage vascular diseases: a systematic review and meta-analysis. BMC Health Serv Res, 13, 533.

33. Dale, J., Caramlau, I., Sturt, J., Friede, T., & Walker, R. (2009). Telephone peer-delivered intervention for diabetes motivation and support: the telecare exploratory RCT. Patient Educ Couns, 75(1), 91-98.

34. California Healthcare Foundation. (2014). Video on Coaching Patients for Successful Self-Management, from http://www.chcf.org/topics/chronicdisease/index.cfm?itemID=133717

35. Clinical Health Coach. (2014). Clinical Health Coach Training Program, from http://clinicalhealthcoach.com/online-overview/

36. Sevick, M. A., Trauth, J. M., Ling, B. S., Anderson, R. T., Piatt, G. A., Kilbourne, A. M., & Goodman, R. M. (2007). Patients with Complex Chronic Diseases: perspectives on supporting self-management. J Gen Intern Med, 22 Suppl 3, 438-444.

37. Bodenheimer T, A., S. (2010). Helping Patients Help Themselves: How to Implement Self-Management Support. Oakland: California HealthCare Foundation.


Content created by Office of the Assistant Secretary for Health (OASH)
Content last reviewed on July 1, 2015
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