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Chronic Disease Self-Management

Chronic Disease Self-Management (CSDM) is one particular type of case management programming. CDSM teaches individuals with chronic diseases how to manage their health, and often CDSM programs include interactive sessions and provide information to help people learn more about the disease. One of the most implemented models is the chronic disease self-management program developed by the Stanford Patient Education Research Center.

The Positive Self-Management Program for HIV (PSMP) is an adaptation of the original CDSM program that aims to meet the unique needs of people living with HIV. PSMP can be conducted in community settings by trained facilitators and helps participants understand the importance of medication adherence and managing their care. Sites can become certified to implement PSMP and most states have at least one site that is certified to conduct training workshops.

Examples of Chronic Disease Self-Management Interventions:

  • Living Well Alabama is an example of a chronic disease self-management course designed by Stanford University to help individuals with chronic conditions, including HIV/AIDS, to take control of the disease and live life to the fullest. The program is open to those living with chronic health conditions and their families, friends, and caregivers. The course is taught for two hours every week over a seven-week period.
  • Living Well Central Oregon is another example of a chronic disease self-management course being implemented in Deschutes County, Oregon. The program is held for two and a half hours weekly for six weeks, and is designed to supplement clinical HIV/AIDS and other chronic disease treatment, and help individuals manage their disease. Trained facilitators conduct the program in community settings such as churches, schools, and libraries.
  • The Every Dose Every Day (E2D2) Mobile Application was developed by the Centers for Disease Control and Prevention (CDC) to assist people living with HIV/AIDS with managing their medications. The application is available on both the iTunes App Store and the Google Play Store. Specific features of the application include appointment reminders, daily dose reminders, information on relevant drugs, options for personalized support, daily tips, and inspirational messages. The application can be beneficial in helping to improve patient-centered adherence to medication regimens.

Considerations for Implementation

Case management and patient navigation can be time- and resource-intensive since people who are living with HIV/AIDS may need support with treatment and medications as well as with housing, transportation, relationships, employment, and in other areas.

In order to coordinate care and connect people with the services they need, case managers and patient navigators need to build relationships and strong connections with a network of medical and social services in the community. Since case management is resource-intensive, organizations will also need to consider the number of case managers necessary to run a program successfully and the appropriate caseload for each case manager or patient navigator.

In addition, patient navigators and case managers will need to work to build trust and establish strong connections with their clients. In rural organizations where peer navigators are used who may be members of similar social groups, special attention should be taken to address confidentiality and privacy concerns.

Maintaining ongoing care over time, especially with transient populations, can be difficult and is an important implementation consideration. In addition, in some rural towns the case managers, HIV medical care providers, and social services providers will not be located in the same town. Coordinated and regular communication between the different care teams will be even more important in these situations to help maintain patients' health statuses.

Resources to Learn More

ARTAS (Antiretroviral Treatment Access Study): Evidence-Based for Linkage to HIV Care and Retention in HIV Care
Document
Explains the Antiretroviral Treatment Access Study, target populations, intervention settings, and evaluation results.
Author(s): Gardner, L.
Organization(s): Centers for Disease Control and Prevention: Division of HIV/AIDS Prevention

Best Practices for Integrating Peer Navigators into HIV Models: Lessons Learned from Peer Navigation Programs
Document
A report providing information and guidance related to implementing an effective HIV peer navigator program. Discusses how to identify target populations and professionalize the mentoring experience. Implementers can use the included templates and checklists to design a new program. 
Organization(s): AIDS United
Date: 5/2015

Brief Strengths-Based Case Management Promotes Entry into HIV Medical Care: Results of the Antiretroviral Treatment Access Study-II
Document
An evaluation of the efficacy of the Antiretroviral Treatment Access program described as an effective program in the Centers for Disease Control and Prevention Compendium of Evidence-Based Interventions.
Author(s): Craw, J.A., Gardner, L.I., Marks, G., et al.
Citation: Journal of Acquired Immune Deficiency Syndromes (JAIDS), 47(5), 597-606
Date: 4/2008

Case Management
Website
A list of resources related to case management, including: guidelines, webinars, and reports outlining strategies for delivering case management services.
Organization(s): TARGET Center: Tools for the Ryan White Community

Engagement in Care Toolkit: Which Engagement in Care Interventions Might Work for your Clinic?
Website
Includes a chart and toolkit outlining several different types of evidence-based case management interventions, and several strengths and challenges of implementing each. Additional detailed information is presented for each intervention, such as contact information for a model program and listings of necessary resources.
Organization(s): AIDS Education & Training Center Program (AETC)

HIV Care Coordination Program: Evidence-Informed for Retention in HIV Care. Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention
Document
A brief explaining the general evidence base for the HIV Care Coordination Program model, including how long the intervention should last, where the intervention should be housed, and characteristics of the target population.
Author(s): Irvine, M.
Organization(s): Centers for Disease Control and Prevention
Date: 5/2015

Improving Linkages and Access to Care
Document
Brief describing the HIV/AIDS model for care coordination to improve individuals' access to care. Includes the general goals of care coordination programs and describes how these programs fit into the HIV care continuum model.
Organization(s): Health Resources and Services Administration (HRSA)
Date: 1/2012