Implementation and evolution of a regional chronic disease self-management program

Area of Science:

• Health Services Research
• Chronic Disease Management
• Behavioral Science

Background:

• Chronic diseases require ongoing self-management support.
• Office-based strategies alone are insufficient for sustained behavior change.
• Community-based programs can complement clinical interventions.

Purpose of the Study:

• To establish a comprehensive, community-based program for chronic disease self-management.
• To improve and sustain self-management support for patients.
• To complement existing office-based behavior change strategies.

Main Methods:

• Created Living Healthy Champlain (LHC), a regional organization.
• Provided peer leader training for the Stanford Chronic Disease Self-Management Program (CDSMP).
• Offered skills training in behavior change approaches for healthcare providers.
• Supported organizations in integrating self-management support.
• Evaluated program impact using the RE-AIM framework.

Main Results:

• Delivered 232 CDSMP sessions at 127 locations, reaching ~4,000 patients.
• Trained over 300 peer volunteers, with 98 remaining active.
• Trained 1,327 additional providers in self-management support models.
• Grew from a pilot to a provincially funded regional initiative.
• Adopted as a provincial model for service delivery.

Conclusions:

• Community-based self-management programs, in partnership with primary care, are effective.
• Broad implementation is feasible for supporting patients with chronic conditions.
• Sustainable models can be developed for enhanced self-management support.