Collaborative management of chronic illness

Ann Intern Med. 1997 Dec 15;127(12):1097-102. doi: 10.7326/0003-4819-127-12-199712150-00008.


In chronic illness, day-to-day care responsibilities fall most heavily on patients and their families. Effective collaborative relationships with health care providers can help patients and families better handle self-care tasks. Collaborative management is care that strengthens and supports self-care in chronic illness while assuring that effective medical, preventive, and health maintenance interventions take place. In this paper, the following essential elements of collaborative management developed in light of behavioral principles and empirical evidence about effective care in chronic illness are discussed: 1) collaborative definition of problems, in which patient-defined problems are identified along with medical problems diagnosed by physicians; 2) targeting, goal setting, and planning, in which patients and providers focus on a specific problem, set realistic objectives, and develop an action plan for attaining those objectives in the context of patient preferences and readiness; 3) creation of a continuum of self-management training and support services, in which patients have access to services that teach skills needed to carry out medical regimens, guide health behavior changes, and provide emotional support; and 4) active and sustained follow-up, in which patients are contacted at specified intervals to monitor health status, identify potential complications, and check and reinforce progress in implementing the care plan. These elements make up a common core of services for chronic illness care that need not be reinvented for each disease.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Chronic Disease / psychology
  • Chronic Disease / therapy*
  • Follow-Up Studies
  • Health Behavior
  • Humans
  • Patient Care Planning*
  • Patient Care Team*
  • Patient Education as Topic
  • Practice Guidelines as Topic
  • Self Care*
  • Social Support