Expanding the reach and strengthening the interaction: A systematic approach to linking patients and medical practices to Healthier Living Colorado (HLC)--the Stanford Chronic Disease Self-Management Program (CDSMP)

Research supports the beneficial role of evidence-based disease-management programs such as the Stanford Chronic Disease Self-Management Program (CDSMP), particularly related to participant utilization of health care resources and confidence in self-managing common issues related to chronic illness. In Colorado, this six-week, lay-led, program focusing on supporting patients in engaging in their own health care, has been renamed Healthier Living Colorado™ (HLC™).

There has been a historical challenge in aligning the resource with medical practices and establishing the relationships required for the medical practices to become a strong referral base. A separate challenge faced by medical practices, particularly now as the medical home model of primary care has taken center stage, is having the resource and skills for incorporating patient self-management support into ongoing patient care activities.

In 2004, a public-private partnership formed between the Colorado Department of Public Health and Environment (CDPHE) and the Consortium of Older Adult Wellness (COAW) to create a regional system that would fill the gap for training, delivery, and fidelity of evidence-based, self-management programs like HLC™. Based on July 2009 program evaluation data, 1437 Coloradans have participated in HLC™. Participants have demonstrated statistically significant increases across six dimensions of confidence measurement; data shows trending toward a decrease in physician visits and hospital stays.

In July of 2009, Colorado Clinical Guidelines Collaborative (CCGC) and COAW began to work together in establishing a model for introducing the HLC™ to primary care practices. The innovative model leverages onsite quality improvement coaching and practices working specifically on incorporating self-managing support into care routines to establish standardized workflows for referring into HLC. Practices are supported in making a perceptual shift from patient education to an understanding of self-management, assessed for readiness to begin actively working on this area of practice transformation, assisted in establishing an initial workflow for engaging patients in a SMS dialogue with the possibility of referral to an HLC class, and supported in making changes to be able to effectively make use of the patient's recent skill-building experience in problem-solving and action planning. Tracking data reflects that since piloting the initial use of this model 17 practices have been referring patients to COAW for classes, 160 total patients have been referred and 45 total patients have participated. Additional evaluation data from the practice team is now also being collected. Further work is being done to refine the model based on lessons learned and additional incoming evaluation data.