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Community-Based Intervention

INTRODUCTION

This chapter provides an overview of community-based interventions aimed at helping people live well with chronic illness. It starts with a discussion of the effects of preventive interventions, including healthy lifestyles, screening, and vaccination of persons living with chronic illness. The chapter then discusses other interventions, including self-management, disease management, treatment adherence management, complementary and alternative medicine, cognitive training, and efforts to increase access for and mobility among those with chronic illness. Finally, it makes the case for monitoring and evaluating implementation of these interventions and their effects and commenting on the need for dissemination and dissemination research.

PREVENTIVE INTERVENTIONS

Evidence-based preventive interventions recommended for the general population are relevant to living well with chronic illness. In some cases, such interventions can affect the disease process, progression, or complications of chronic disease. For example, the Look AHEAD trial for people with diabetes has shown than an intensive 1-year intervention focusing on diet, exercise, and weight loss improved weight, diabetes control, and cardiovascular risk factors, with effects persisting 4 years after the intervention (Look AHEAD Research Group and Wing, 2010; Look AHEAD Research Group et al., 2007). Even when a particular health behavior is



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4 Community-Based Intervention INTRODUCTION This chapter provides an overview of community-based interventions aimed at helping people live well with chronic illness. It starts with a discussion of the effects of preventive interventions, including healthy life- styles, screening, and vaccination of persons living with chronic illness. The chapter then discusses other interventions, including self-management, disease management, treatment adherence management, complementary and alternative medicine, cognitive training, and efforts to increase access for and mobility among those with chronic illness. Finally, it makes the case for monitoring and evaluating implementation of these interventions and their effects and commenting on the need for dissemination and dis- semination research. PREVENTIVE INTERVENTIONS Evidence-based preventive interventions recommended for the general population are relevant to living well with chronic illness. In some cases, such interventions can affect the disease process, progression, or complica- tions of chronic disease. For example, the Look AHEAD trial for people with diabetes has shown than an intensive 1-year intervention focusing on diet, exercise, and weight loss improved weight, diabetes control, and cardiovascular risk factors, with effects persisting 4 years after the inter- vention (Look AHEAD Research Group and Wing, 2010; Look AHEAD Research Group et al., 2007). Even when a particular health behavior is 151

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152 LIVING WELL WITH CHRONIC ILLNESS not directly related to a person’s chronic illness (e.g., smoking and arthri- tis), adoption of healthy lifestyles by individuals with chronic illnesses can serve to “strengthen the host,” optimize overall health, and make them less vulnerable to further health threats and disability. Lifestyle behavior change cannot generally substitute for effective medical management of chronic illness, where it is available, but often supports “living well”—improving quality of life, ameliorating symptoms, and optimizing functional status. Below we summarize evidence related to benefits of preventive interven- tions for those with chronic illness as well as evidence-based strategies for optimizing adoption of the preventive intervention. For this overview we have relied primarily on systematic reviews and meta-analyses from such groups as the U.S. Preventive Services Task Force (USPSTF), Cochrane Database System Reviews, the Guide to Community Preventive Services of the Centers for Disease Control and Prevention (CDC), and the Advisory Committee on Immunization Practice (ACIP). In some cases, the research summarized in these reviews has emphasized the benefits of prevention for a particular chronic disease, but in general the body of research on living well with chronic disease is limited. Lifestyle Behaviors Physical Activity Increasing physical activity has a number of benefits for those with chronic illnesses, including decreasing the risk of cardiovascular disease, some cancers, and diabetes, as well as improving physical functioning (Physical Activity Guidelines Advisory Committee, 2008). Physical activity interventions have been shown to benefit those with chronic illnesses as well as the general population. Whereas exercise can be expected to improve fit- ness in most individuals, for people with chronic illnesses, what is critical is determining the effects on quality of life, function, and progression of their illness. For example, a systematic review of physical activity trials in cancer survivors reports improvements related to fatigue, functional aspects of quality of life, anxiety, and self-esteem involving exercise (Speck et al., 2010). For type 2 diabetes patients, structured exercise programs, physical activity, and dietary advice from a physician potentially affect the disease course, reducing HbA1c levels (Umpierre et al., 2011). The American Col- lege of Sports Medicine and the American Diabetes Association have issued a joint position statement supporting participation in regular physical ac- tivity for individuals with type 2 diabetes (Colberg et al., 2010). Increas- ing physical activity through exercise also helps those with depression. A Cochrane review of 23 randomized controlled trials (RCT) showed that participants in exercise interventions showed greater reductions in depres-

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153 COMMUNITY-BASED INTERVENTION sion both following treatment and at longer-term follow-up compared with a no-treatment control group (Mead et al., 2009), although, some method- ological weaknesses were noted in the trials (e.g., inadequate blinding of outcome assessment). Evidence also exists that exercise may help relieve de- pressive symptoms of older adults who have osteoarthritis (OA) (Yohannes and Caton, 2010). The Arthritis Foundation and CDC, in their National Public Health Agenda for Osteoarthritis (2010), recommended promotion of low-impact aerobic and strength-building exercise for adults with OA in the hip and/or knee. OA research indicates that land-based exercise de- creases pain, fatigue, and stiffness and improves performance on functional assessments (Callahan et al., 2008; Hughes et al., 2006). A Cochrane review of exercise for knee OA concluded that both land-based and aquatic exer- cise has short-term benefit in terms of reduced pain and improved physical functioning (Bartels et al., 2007; Fransen and McConnell, 2008). Physical activity appears to be helpful to people with other chronic illnesses as well. For example, aerobic physical activity, alone or when included in multicomponent interventions, has also been shown to be beneficial to patients with fibromyalgia syndrome, having moderate-sized effects on pain, fatigue, depressed mood, and quality of life (Häuser et al., 2009, 2010). A Cochrane review on exercise for fibromyalgia indicated that moderate aerobic exercise may benefit overall well-being and physi- cal function, whereas strength training appears more beneficial in terms of reducing pain, tender points, and depression (Busch et al., 2007). A limited number of studies have been conducted to test the effects of exercise on dementia. Results of the studies have been mixed, and the methodology has been of low to moderate quality, but some studies have indicated that participation in exercise is associated with such outcomes as better mobil- ity and physical performance and improvement in activities of daily living (ADLs) (Blankevoort et al., 2010; Littbrand et al., 2011; Potter et al., 2011; Vreugdenhil et al., 2011); however, it is unclear whether exercise has an effect on cognitive functioning in this population (Littbrand et al., 2011). Although substantial evidence has accrued for the benefits of physical activity for people with a range of chronic illnesses, there is limited evidence to indicate what type, duration, and intensity of exercise is most helpful for improving function, quality of life, and disease progression for most chronic illnesses, nor are there sufficient evidence-based programs to help individu- als with chronic illnesses to successfully adopt and maintain exercise. A survey conducted of physical activity programs for the elderly in seven U.S. communities highlights the problems of both insufficient demands from this population as well as insufficient program capacity. The survey showed that the programs were serving only approximately 6 percent of the elderly population; however, less than 4 percent of the programs had waiting lists for their services (Hughes et al., 2005).

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154 LIVING WELL WITH CHRONIC ILLNESS There are few evidence-based community programs specifically for in- dividuals with chronic illnesses that have been shown to increase physical activity and improve outcomes, although programs developed for individu- als with OA have been shown to be effective and successfully implemented. For example, a randomized trial of the 8-week Arthritis Foundation’s Exer- cise Program intervention showed effects on pain, fatigue, and self-efficacy, with symptom improvements maintained at follow-up 6 months later. The prevalence of a particular chronic disease may limit the usefulness of hav- ing disease-specific physical activity programs for many chronic diseases. However, physical activity programs that are adaptable to individual needs may be appropriate for people with a range of chronic illnesses. An example is EnhanceFitness, an evidence-based physical activity program developed for older adults. EnhanceFitness is a 1-hour class that meets 3 times per week and includes moderate intensity aerobic exercise, strength training, flexibility, and balance-enhancing exercises. Benefits of the program include prevention of age-related decline in health status as measured via the SF-36 health survey (Wallace et al., 1998) and improved physical performance (Belza et al., 2006); participation in the program is also associated with reduced health care costs for individuals making heavy use of the program (Ackermann et al., 2008). Several interventions are recommended by the CDC’s Guide for Com- munity Preventive Services to increase physical activity (Community Preventive Services Task Force, 2005a). Although these evidence-based interventions have not necessarily been tested in populations with chronic illnesses, several have been tested in older adults, who are more likely to suffer from chronic illnesses. Individually tailored health behavior pro- grams also have sufficient evidence to be recommended by the task force. Such programs include evidence- and theory-based behavioral strategies to modify behavior, including goal setting and self-monitoring, rewarding positive changes in behavior, structured problem-solving skills, soliciting social support for the behavior changes, and preventing relapse. Interven- tions to increase social support for physical activity in community settings, such as exercise buddy systems or walking groups, are also recommended. Community-wide campaigns that involve sustained effort to promote high- visibility messages about increasing physical activity have been shown to be effective and may be combined with individual-level education/counseling efforts. Finally, recommended policy changes and environmental interven- tions include community-scale and street-scale urban design and land use policies, increased access to places for physical activity combined with informational outreach, and point of decision prompts to use stairs (Com- munity Preventive Services Task Force, [d]). Urban design features that enhance activity include land use policies that influence the proximity of stores and other destinations to residential areas, aesthetics and safety, and

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155 COMMUNITY-BASED INTERVENTION connectivity/continuity of sidewalks and streets (Community Preventive Services Task Force, [b]). Diet Diet and physical activity are often linked when offering interven- tions for the prevention of chronic dieases. Although recommendations for healthy diets come from a variety of sources, they offer similar patterns of intake. Recommended Dietary Allowances (RDAs), Dietary Reference In- takes (DRIs), and the Dietary Guidelines for Americans are fairly consistent in recommending a diet that maintains a healthy weight, encouraging a rich intake of fresh fruits and vegetables (preferably those that are dark green, red, or orange), complex carbohydrates (whole grains), and low-fat dairy products and minimizing saturated fats (except for mono- or polyunsatu- rated fatty acids), lowering the consumption of salt, and taking in adequate fluids. These recommendations are also consistent with the Healthy People 2010 and Healthy People 2020 targets. Individuals with chronic illnesses may encounter socioeconomic is- sues that contribute to food insecurity, a situation in which individuals have to make choices about how to spend limited income. Fresh fruits and vegetables may be expensive, whereas rice and potatoes are not. Food inse- curity may also encompass challenges in procuring or preparing adequate food. Those with disabilities may have more problems with being able to independently shop or cook food and may rely on prepared or processed products, which are often high in salt and fat. It is difficult for some older people to make healthy choices if they have not been educated in the basics of nutrition. Identifying nutritional deficiencies is often difficult, and both poor nutrition and obesity may have underlying etiologies that are not directly caused by poor choices about foods consumed. Eating can become a challenge for those who have to navigate making healthy food choices adhering to the multiple public health messages to consume less sodium, less fat, more unsaturated fats, less trans- fat, fewer triglycerides, more fruits and vegetables, as well as other dietary modifications associated with managing their chronic illness. Tobacco Smoking cessation is an important behavior-change target for people with chronic illnesses, particularly those whose illness is related to their tobacco use (HHS, 1990). Data from the National Health Interview Sur- vey indicate that many individuals with smoking-related chronic illnesses continue to smoke; the prevalence of smoking among individuals with a smoking-related chronic illness is 36.9 percent, 23 percent among individu-

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156 LIVING WELL WITH CHRONIC ILLNESS als with chronic illnesses that are not smoking related, and 19.3 percent in people with no chronic illness (Rock et al., 2007). Gritz et al. (2007) reviewed the literature with regard to benefits of smoking cessation and effectiveness of interventions for individuals with cardiovascular disease, chronic obstructive pulmonary disease, diabetes, asthma, cancer, and AIDS. For these diseases, continued smoking has been shown to increase the risk of disease exacerbation or complications. Smoking cessation interventions, delivered primarily in health care settings or in the context of self-manage- ment programs, have shown mixed results with regard to efficacy. More research is needed to determine optimal smoking cessation intervention approaches for individuals with chronic illnesses, as well as whether exist- ing smoking cessation services are effective and accessible to individuals with chronic illness. A state of the science conference held by the National Institutes of Health (NIH) on smoking cessation in adults (including special populations) concluded that self-help strategies alone were not effective at increasing cessation rates, but combined counseling and pharmacotherapy were largely effective (Ranney et al., 2006). However, few studies focused on ways to reach special populations, such as those with chronic illness. One approach, intensive smoking cessation counseling delivered to hospi- talized patients, has not been shown to be effective. The 2008 nicotine dependence treatment guidelines (HHS and Public Health Service, 2008) conclude that cessation treatment, including both counseling and pharmacological treatment, is effective for smoking cessa- tion in patients with cardiovascular disease, lung disease, and cancer, but that there were insufficient trials in HIV/AIDS populations. For individuals with psychiatric illnesses, who have high smoking rates compared with the general population, smoking cessation pharmacological (buproprion SR and nortriptyline for depressed individuals and nicotine replacement and buproprion SR for individuals with schizophrenia) and counseling interven- tions have also shown effectiveness. The guidelines concluded that there is insufficient evidence to indicate that individuals with psychiatric disorders benefit more from interventions tailored to the psychiatric disorder or symptoms than standard treatments. A more recent systematic review of smoking cessation interventions for individuals with severe mental illness confirmed that such individuals are able to quit smoking with pharma- cological (buproprion and nicotine replacement therapy) and behavioral interventions (individual and group therapy) that are effective in the general population. Furthermore, those who are stable at the initiation of treatment do not suffer increases in psychiatric symptoms (Banham and Gilbody, 2010). Individuals with chronic illnesses can also benefit from community efforts to encourage tobacco use cessation and reduce exposure to sec- ondhand smoke. Tobacco policies in the community decrease exposure to

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157 COMMUNITY-BASED INTERVENTION secondhand smoke, and those in the workplace increase smoking cessation and decrease secondhand smoke exposure. In the workplace, incentives and competitions can be effective in increasing tobacco cessation when com- bined with other efforts. Recommended interventions for smoking cessation include mass media campaigns when combined with other interventions, an increase in the unit price of tobacco products, provider reminders with and without provider education, reduced out-of-pocket costs for tobacco cessa- tion, and multicomponent interventions that include telephone counseling (Community Preventive Services Task Force, [a]). Screening and Vaccination USPSTF has developed recommendations for clinical preventive services based on systematic reviews of the literature. With few exceptions, recom- mendations of USPSTF apply as well to people with chronic illnesses as they do to people without chronic illness. The only exceptions to general preven- tion recommendations for people with chronic illnesses involve situations where the presence of the chronic illness changes the magnitude of benefit or harm from the specific preventive service. For example, if the chronic illness reduces life expectancy to a substantial degree, the potential benefit from the preventive service (e.g., screening mammography in women with metastatic lung cancer) may be reduced and the preventive service becomes inappropriate. Likewise, if the chronic illness increases the testing burden or the potential psychological or physical harm of the preventive service (e.g., colorectal cancer screening in people with advanced dementia), again the preventive service is inappropriate. As with individual preventive services for anyone, it is important for the health care system to assist people with chronic illnesses to consider the potential benefits and harms to make an in- formed decision about preventive services. Sometimes, people with chronic illnesses may decide that the burden of testing and possible work-up and treatment is not worth the potential benefit, or that the added burden of yet another medication (even if prophylactic) is more than they are willing to bear. Some people with chronic illnesses may decide that, given their situa- tion, some preventive services are just not a high enough priority for them to spend the time and energy (both physical and emotional) to engage in them. In these situations, the health care systems should respect and support the person’s decision (Sawaya et al., 2007). Chronically ill individuals often suffer from multiple chronic conditions (MCCs) (HHS, 2010), and thus relevant outcomes for preventive interven- tions may be broader than those traditionally used to assess effectiveness of preventive services and include multiple domains. Some of these domains may be represented by a multiplicity of measures that create difficulties for clear, straightforward interpretation. The strategic framework on MCCs of

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158 LIVING WELL WITH CHRONIC ILLNESS the U.S. Department of Health and Human Services (HHS) identifies the definition of relevant health outcomes for individuals with MCCs as one of its priority objectives (HHS, 2010). Furthermore, the specific benefit of a preventive intervention for individuals with chronic illnesses may not be known. Randomized clinical trials of preventive services often exclude individuals with chronic illnesses or recruit them in insufficient numbers to allow subgroup analyses that could identify benefits and risks of the intervention. The risk of harm from the intervention might be higher for individuals with chronic illnesses. For example, in screening for cancer in those with heart failure or chronic obstructive pulmonary disease (COPD), consideration should be made of the risk of overtreatment and the indi- vidual’s ability to tolerate treatment if a cancer is identified. As another example, people who are older and with chronic illnesses suffer more complications from screening colonoscopy than do younger people without chronic illnesses (Warren et al., 2009). Influenza vaccines are one clinical preventive intervention for which there is evidence of benefit for individuals with chronic illness. The PRISMA study was a nested case-control study that evaluated the risk reduction of influenza vaccine among adults between the ages of 18 and 64 with chronic illness (Hak et al., 2005). In this age group, influenza vaccination prevented 78 percent of deaths, 87 percent of hospitalizations, and 26 percent of visits to a general practitioner. Influenza vaccine is recommended for all individu- als age 6 months and older, but special emphasis is placed on immunizing individuals at higher risk of complications, including those with chronic illnesses, such as pulmonary and cardiovascular disease (except hyperten- sion); renal, hepatic, and hematological diseases; neurological disorders; and metabolic disorders, such as diabetes. Individuals who are immuno- compromised, because of either an illness or a treatment, are also a high priority for influenza vaccine outreach (CDC, 2011). Because these clinical preventive services are for the most part delivered through health care settings, and individuals with chronic illnesses may have more contact with the health care system, they may have increased opportunities to receive preventive care. A study of preventive health care in individuals with lupus found that they had comparable levels of cancer screening to a general population sample and a sample of patients with other chronic illnesses (diabetes, asthma, and heart disease). The sample with lupus had higher rates of influenza vaccination and lower rates of pneumococcal vaccination than the general population had, and the pa- tients with other chronic illnesses had lower rates of both types of vac- cination (Yazdany et al., 2010). Having a primary care provider and a rheumatologist involved in care increased the likelihood that individuals with lupus received the influenza vaccine. Baldwin and colleagues (2011) studied preventive care in colorectal cancer survivors from the year prior

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159 COMMUNITY-BASED INTERVENTION to diagnosis to up to 8 years postdiagnosis using SEER (Surveillance, Epidemiology, and End Results)–Medicare data. Patients with stage 0 or 1 colorectal cancer had higher rates of mammography screening and having the influenza vaccine than did those with stage 2 or 3 cancer and controls. For individuals with stage 2 or 3 cancer, their use of mammography and in- fluenza vaccine increased from prediagnosis through posttreatment and sur- vivorship phases, indicating that perhaps either the “teachable moment” of the cancer diagnosis or their increased contact with the health care system facilitated their receipt of preventive services (Baldwin et al., 2011). The Guide to Community Preventive Services recommends a number of measures to increase uptake of screening in the general population, which would be likely to impact those with chronic illnesses as well. Education efforts using one-to-one methods (breast and cervical cancer screening) or small-group education (breast cancer screening only) as well as small media (videos and print material to encourage people to obtain screening) have shown to increase screening uptake. Client reminder systems (breast and cervical cancer screening), a reduction in structural barriers (breast cancer screening only), and a reduction in out-of-pocket costs (breast cancer screen- ing only) also increase screening rates (Community Preventive Services Task Force, [a]). Offering the influenza vaccination in the workplace to both health care and non–health care workers is recommended for increasing in- fluenza vaccination rates and would be a useful adjunct to offering vaccina- tions in health care settings (Community Preventive Services Task Force, [c]). Barriers to Lifestyle Behavior Change for Individuals with Chronic Illness Efforts to increase adoption of healthy lifestyle behaviors among in- dividuals affected by chronic illness should be undertaken with sensitivity to the additional barriers often faced by these populations. Individuals with low socioeconomic status, and African Americans and Hispanics, are more likely to experience chronic illnesses and impaired functional status (Kington and Smith, 1997), and therefore they may live in neighborhoods that have a high density of advertising of tobacco and alcohol products and outlets where such products may be purchased (Barbeau et al., 2005; Gentry et al., 2011), as well as poor access to fitness and recreation facili- ties, or supermarkets that sell fresh fruits and vegetables (Estabrooks et al., 2003; Larson et al., 2009). Furthermore, fitness and recreation facilities, as well as outdoor areas supporting physical activity, may not be accessible or welcoming to individuals with disabilities (Rimmer et al., 2004, 2005). Additionally, neighborhood safety is generally poorer in low socioeconomic status (SES) neighborhoods (Wilson et al., 2004) and may disproportion- ately affect people with chronic illnesses, particularly those with functional limitations who are more vulnerable to violence (Levin, 2011), falls, and

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160 LIVING WELL WITH CHRONIC ILLNESS physical barriers. Fear of violence in the community may suppress physi- cal activity and also affects healthy eating patterns. Disparities such as these point to the need for environmental and policy approaches to sup- porting healthy lifestyle behavior among individuals with chronic illnesses (Brownson et al., 2006), including availability and accessibility of outlets for physical activity and healthy eating, and addressing violence in the com- munity (Cohen et al., 2010); such approaches may be even more important for these populations than the general population. Other Living Well Interventions Self-Help Management In 2005, 133 million people in America had at least one chronic illness (Partnership for Solutions National Program Office, 2004). About 25 per- cent of individuals with chronic illnesses have activity impairments (Part- nership for Solutions National Program Office, 2004). The management of chronic illness often requires a multifactored approach among health care team members, informal caregivers, and the patient. One approach to minimizing the costs and instilling individual responsibility and confidence is the development of self-management programs. These programs offer information and behavioral strategies that provide tools for individuals to use in caring for their chronic illness. These programs need to be based on what the patients perceive as problematic, not on what health care provid- ers think the focus of education should be (Lorig and Holman, 2003). Self-management requires a set of skills that can be taught to individu- als with chronic illness. These include problem solving, decision making, resource utilization, developing a patient-provider partnership, and taking action (Lorig and Holman, 2003). The development of self-management strategies is often done on an individual case basis. The dissemination of an evidence-based program for the self-management of chronic disease in the community is a recent phenomenon (Lorig et al., 2005). A 6-week program called the Chronic Disease Self-Management Program (CDSMP) was developed by a group of investigators at Stanford University in the 1990s. The program dissemination was implemented and evaluated at Kaiser Permanente, an integrated health care system that serves well over 8 million people (Lorig et al., 2005). In a 2-year follow-up, the investigators examined health status and health resource utilization (Lorig et al., 2001a). Health resource utilization, measured as the number of emergency room and outpatient visits, was reduced, and there was an improvement in self- efficacy or the confidence in one’s ability to deal with health problems. In a smaller study that measured outcomes after one year, there were similar

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161 COMMUNITY-BASED INTERVENTION results: fewer emergency room and outpatient visits, although the results were not statistically significant (Lorig et al., 2001b). Self-management of chronic diesases has since been evaluated in a variety of clinical trials. There are conflicting reports of their effectiveness and essential components (Chodosh et al., 2005). In a meta-analysis of the literature, 780 studies were reviewed and 53 were selected for analysis, including 26 diabetes programs, 14 osteoporosis studies, and 13 hyperten- sion studies (Chodosh et al., 2005). The diabetes and hypertension stud- ies reviewed showed clinical improvements in the participants’ outcome measures (HbA1c and both systolic and diastolic blood pressure), but the osteoarthritis participants had only minimal impact on the outcome mea- sures for pain and function. However, the investigators reported that the meta-analysis had limitations, in that the studies included were of variable quality. Self-management programs have been applied to different chronic disease interventions for osteoarthritis (Wu et al., 2011), depression (Zafar and Mojitabai, 2011), diabetes (Ismail et al., 2004; Moore et al., 2004), hypertension (Schroeder et al., 2004a, 2004b), and others (Chodosh et al., 2005; Gardetto, 2011). There are other self-management programs, most notably Matter of Balance, a self-management program designed to decrease the risk of falls. The efficacy of a fall prevention program seems to be linked to a perception of need on the part of the individual (Calhoun et al., 2011). A recent meta- analysis concluded that fall prevention programs do reduce falls by 9–12 percent as reported in the literature (Choi and Hector, 2011). Participation rates in patient self-management programs seem variable, depending on the program, the population, and the locale (Bruce et al., 2007). A recent study conducted in Canada that reviewed the implementa- tion and success of a self-management program for individuals with chronic illnesses found a general lack of understanding about self-management, a minimum of evidence-based practices, and a tendency to focus on a single illness entity. The challenge was that most of the patients had multiple comorbidities and self-management programs did not account for this and proved to be a burden for patients and providers alike (Johnston et al., 2011). Disease Management Disease management programs are widely used by health plans and overlap with self-management programs. Disease management programs seek to detect patients with chronic illnesses and to increase their use of self-management and coordinated care with an eye toward improving out- comes and controlling costs (Bernstein et al., 2010). In 2010, 67 percent of large employers consisting of 200 or more workers included disease

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