Tools for building clinic-community partnerships to support chronic disease control and prevention.

Purpose: Developing partnerships among health care clinics and community organizations is an important strategy for increasing resources and supports for chronic disease care and management. Although several tools assessing partnership characteristics exist, tools to assess the progression from partnership development to the achievement of specific short-term, intermediate, and long-term outcomes have not been developed to date. The purpose of this article is to introduce tools developed by the Diabetes Initiative of the Robert Wood Johnson Foundation to fill that gap.

Perspectives on self-management from the Diabetes Initiative of the Robert Wood Johnson Foundation.

Purpose And Method: Review and highlight findings from the projects of the Diabetes Initiative of the Robert Wood Johnson Foundation described in this special supplemental issue.

Results: The broad framework for self-management around which these programs were developed, "Resources and Supports for Self Management," includes individualized assessment, collaborative goal setting, building skills for self-management, ongoing follow-up and support, community resources, and continuity of quality clinical care. Lessons learned include the central role of community health workers in self-management, the importance of ongoing follow-up and support to sustain self-management, varied program approaches to depression and negative emotion, the importance of organizational infrastructure to support self-management programs, and the contributions of clinic-community partnerships.

Use of the transtheoretical model to enhance resources and supports for diabetes self management: lessons from the Robert Wood Johnson Foundation Diabetes Initiative.

Purpose: The purpose of this article is to describe how Resources and Supports for Self Management (RSSM) and strategies of the transtheoretical model (TTM) intersect to produce a comprehensive approach resulting in cutting-edge diabetes programs.

Methods: Specific components of RSSM, especially individualized assessment, collaborative goal setting, and enhancing skills, are reviewed in terms of contributions to the TTM.

Results: Specific examples from the Diabetes Initiative of using TTM constructs from 5 projects are shown to illustrate the first 3 RSSM constructs: individualized assessment, collaborative goal setting, and skill building.

Characteristics of organizational resources and supports for self management in primary care.

Purpose: The purpose of this article is to describe components of organizational support for self-management in primary care and provide illustrations of each of these components from the Diabetes Initiative's Advancing Diabetes Self Management (ADSM) projects.

Methods: Elements of organizational resources and supports for diabetes self-management in primary care were developed from the experience of the ADSM projects and in collaboration with Diabetes Initiative staff and experts.

Results: Eight elements of organizational support for self-management were identified: (1) the establishment of patient care teams, (2) continuity of care, (3) coordination of referrals, (4) documentation of self-management support, (5) ongoing quality improvement, (6) patient input, (7) staff training and education, and (8) integration of self-management into primary care.

The Robert Wood Johnson Foundation Diabetes Initiative: demonstration projects emphasizing self-management.

Purpose: The purpose of the Diabetes Initiative of the Robert Wood Johnson Foundation is to demonstrate feasible and sustainable approaches to promoting diabetes self-management in primary care and community settings.

Methods: The Diabetes Initiative of the Robert Wood Johnson Foundation includes 14 demonstration projects in primary care settings and in community-clinical partnerships. Projects serve predominantly indigent populations from varied cultural and linguistic backgrounds in urban, rural, and frontier settings around the United States.

Ecological approaches to self-management: the case of diabetes.

In the Diabetes Initiative of The Robert Wood Johnson Foundation, an ecological perspective helped identify the following key resources and supports for self-management (RSSM): individualized assessment, collaborative goal setting, skills enhancement, follow-up and support, access to resources, and continuity of quality clinical care. These RSSM reflect the grounding of diabetes self-management in the context of social and environmental influences. Research supports the value of each of these key resources and supports.