Publications & Resources

Helping Patients to Manage Chronic Disease

Almost half all adults have at least one chronic illness, and 50% of adults aged 65 and older have at least two. Helping patients manage their chronic conditions is a challenge, especially in busy community health center settings where multiple health issues are addressed and statistics show there is a pressing need for this kind of help.

The good news is that health center patients are more than three times as likely to seek care for serious chronic conditions as patients receiving care in private practices. And today, many health centers have found a perfect solution to address their patient needs — a well tested and federally supported evidence-based workshop called the Chronic Disease Self-Management Program (CDSMP).

Developed at Stanford University in the early 1990s, CDSMP is a six-week course where individuals with chronic diseases, such as heart disease, hypertension, cancer, stroke, arthritis and diabetes learn and practice problem-solving, coping, and communication skills to deal with their condition. They discover lifestyle strategies for good health, including diet, exercise, medications, managing pain and fatigue, living with disability, and overcoming depression.

In addition to CDSMP, Stanford University has developed disease specific workshops including the Diabetes Self-Management Program and Arthritis Self-Management Program. These six-week, 2.5-hour classes are highly interactive, confidence building, and fun, and are led by community-based facilitators who live with chronic conditions themselves and have received extensive training. An online version of the program is also available at

CDSMP has been extensively evaluated through repeated, randomized controlled trials. A review of major published studies found that CDSMP results in significant, measurable improvements in the health and quality of life of people living with chronic conditions. The program also appears to save enough through reductions in health care expenditures to pay for itself within the first year. Studies have indicated fewer emergency room visits, inpatient stays, and outpatient visits, fewer hospitalizations and a health care cost savings of approximately $590 per participant.

Researchers also have found that participants in the program:

• Experience fewer physician visits
• Decrease their overall disability
• Increase their exercise
• Develop better coping strategies and symptom management
• Communicate better with their physicians
• Improve their self-rated health, disability, social and role activities, and health distress
• Have more energy and less fatigue

Because the program has consistently demonstrated positive results, community health centers in several states are now offering CDSMP.

• New Jersey: As part of efforts to reach rural populations, health centers have funded training and implementation of CDSMP at some of their locations. In addition, the state’s pending proposal for a Medicaid incentive grant would pair health centers and the Department of Health and Senior Services to provide CDSMP workshops.
• West Virginia: Health centers are testing a video and interactive web-based program to inform health care teams and patients about self-management skills and motivate action at two centers. The program is called “Manage Your Health – One Step at a Time.”
• New Hampshire: A presentation at a community health center in Portsmouth resulted in a team plan to integrate CDSMP referrals for people with chronic conditions into that practice. Outreach visits to health centers also have been conducted.
• Oregon: The state has implemented a Community Health Center Patient Self-Management Collaborative that includes five health centers. The centers work in teams to develop the systems, training, and staffing necessary to integrate referrals to community-based self-management programs into their regular visits with clients afflicted with chronic health conditions. Each clinic has selected a “community ambassador” from one or more evidence-based program, and clinic staff make referrals to the programs and integrate them into their practices.

NOTE: Although many health centers offer CDSMP, implementation is not system-wide. The National Council on Aging is interested in working with the National Association of Community Health Centers to help more health centers implement CDSMP in-person and online workshops to reach more patients. The goal is to make CDSMP part of the standard package of patient engagement tools used at all health centers.

For more information on this initiative, please contact Kelly Horton ( at the NCOA Center for Healthy Aging. For more information about CDSMP, visit or the Stanford Patient Education Research Center

Related Documents:

01-10-2012 Helping Patients to Manage Chronic Disease (186kb)

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