Chronic Disease Self-Management
Disease Self-Management (CDSM) 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.
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
Examples of Chronic Disease Self-Management Interventions:
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.
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
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 areas, 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'
Resources to Learn More
(Antiretroviral Treatment Access Study): Evidence-Based for Linkage to HIV Care and Retention in HIV
Explains the Antiretroviral Treatment Access Study (ARTAS), a case-management intervention linking newly
diagnosed HIV-positive individuals to care and sustained care. Discusses several ways for the case manager to
develop an effective relationship with clients and create a plan to identify their healthcare needs and barriers
to care, as well as link them to community resources such as housing and food banks.
Author(s): Gardner, L.
Organization(s): Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention (CDC)
Offers a list of resources related to case management including: guidelines, webinars, and reports outlining
strategies for delivering medical case management services.
Organization(s): TargetHIV, HRSA's Ryan White HIV/AIDS Programs
in Care Toolkit: Which Engagement in Care Interventions Might Work for Your Clinic?
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 supporting resources.
Organization(s): AIDS Education & Training Center Program (AETC)
Care Coordination Program: Evidence-Informed for Retention in HIV Care
Explains the HIV Care Coordination Program model for retaining individuals in HIV treatment and care offering
home- and field-based patient navigation services. Details specific components of the model including outreach,
social services, multidisciplinary team care and decision making, patient navigation, adherence support, and
Author(s): Irvine, M.
Organization(s): New York City Department of Health and Mental Hygiene - HIV Care & Treatment Research &
Evaluation, Centers for Disease Control and Prevention (CDC)