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Supporting self-management for patients with complex medical needs: recommendations of a working group

Clinical Research Unit, Kaiser Permanente, PO Box 378066, Denver, CO, 80237-8066, USA, Elizabeth.bayliss{at}kp.org, Department of Family Medicine, University of Colorado Health Sciences Center, Denver, CO, USA

H.B. Bosworth

Center for Health Services Research in Primary Care, Durham VAMC, Durham NC, USA, Departments of Medicine, Psychiatry, and School of Nursing, Duke University Medical Center, Durham, NC, USA

P.H. Noel

VERDICT HSR&D Center, South Texas Veterans Health Care System, TX, USA, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA

J.L. Wolff

Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

T.M. Damush

Roudebush VAMC HSRD Center of Excellence on Implementation of Evidence Based Practices, VA Stroke QUERI Center, Indiana University Center for Aging Research, Regenstrief Inc., Indianapolis, IN, USA

L. Mciver

Department of Veterans Affairs, Health Services R & D Service, Washington, DC, USA

Increasing numbers of persons live with complex chronic medical needs and are at risk for poor health outcomes. These patients require unique self-management support, as they must manage many, often interacting, tasks. As part of a conference on Managing Complexity in Chronic Care sponsored by the Department of Veterans Affairs, a working group was convened to consider self-management issues specific to complex chronic care. In this paper, we assess gaps in current knowledge on self-management support relevant to this population, report on the recommendations of our working group, and discuss directions for future study. We conclude that this population requires specialized, multidimensional self-management support to achieve a range of patient-centred goals. New technologies and models of care delivery may provide opportunities to develop this support. Validation and quantification of these processes will require the development of performance measures that reflect the needs of this population, and research to prove effectiveness.

Key Words: Chronic disease • Health behaviours • Multimorbidity • Patient—provider communication • Self-management

Chronic Illness, Vol. 3, No. 2, 167-175 (2007)
DOI: 10.1177/1742395307081501


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