This document discusses patient self-management support, which involves helping patients manage their chronic conditions through education, goal-setting, and developing self-management skills. It describes strategies for supporting self-management, including assessing patient needs and barriers, collaborative goal-setting, enhancing problem-solving skills, and arranging follow-up care. The document also outlines how practices can meet NCQA standards for self-management support and provides resources for implementing self-management programs.

1. Patient Self-Management Support
NCQA PCMH Standard 4

2. Presented by:
Medina Wilson, BS, CPC
Practice Support Coordinator
Wake Forest School of Medicine
NW AHEC
mewilson@wakehealth.edu

3. Objectives
Describe the key concepts and principles of self- management and self-management support
Identify specific strategies, tools and resources for engaging and activating patients and families in chronic illness care
Describe strategies for redesigning care to enhance the efficient delivery of self- management support

4. What is self-management?
“The individual’s ability to manage the symptoms, treatment, physical and social consequences and lifestyle changes inherent in living with a chronic condition.”
Barlow et al, Patient Educ Couns 2002;48:177

6. Informed,
Activated
Patient
Productive
Interactions
Prepared,
Proactive
Practice Team
Delivery
System
Design
Decision
Support
Clinical
Information
Systems
Self-
Management
Support
Health System
Resources and
Policies
Community
Health Care Organization
Chronic Care Model
Improved Outcomes

7. What is Self-Management Support?
–“The systematic provision of education and supportive interventions to increase patients’ skills and confidence in managing their health problems, including regular assessment of progress and problems, goal setting, and problem-solving support.”
(IOM, 2003)

8. Self-Management Support
•Emphasize the patient’s central role in managing their illness
•Assess patient’s beliefs, behavior and knowledge.
•Advise patients by providing specific information about health risks and benefits of change.

9. Self-management support, cont.
•Assist patients with problem-solving by identifying personal barriers, strategies, and social/environmental support.
•Arrange a specific follow-up plan.

10. Self-Management Support
A collaborative process to help people to:
Understand/Choose treatments
Identify and set goals
Adopt and change behaviors
Cope and overcome barriers
Follow-through

11. Self-Management Support is NOT
•Didactic Patient Education
•Lecturing
•Inducing fear
•Finger-wagging
•“You should”
•Shaming
•Waiting for a patient to ask

12. What Works – Research Evidence?
Addressing knowledge is necessary but not sufficient to produce changes in chronic illness care outcomes
Key components that have been found to work well to support self- management include:
Involving patients in decision making
Assessment of patient-specific needs and barriers
Goal setting
Enhancing skills, problem-solving
Follow-up and support
Increasing access to resources
(Bodenheimer et al, 2002 ; Glasgow et al, 2003; Fisher et al, 2005)

13. What are the Desired Outcomes of Self-Management Support?
People with chronic conditions (and their families) are more:
•Aware and Informed
•Engaged
•Activated
•Empowered
•Confident they can self-manage
•Partners with health care providers

14. Why is self-management so important? What is different?
•Clinical outcomes are dependent on patient actions.
•Patient self-management is inevitable.
•The provider’s role is to be in partnership with the patient
•Professionals are experts about diseases, patients are experts about their own lives.

15. Emphasizing the patient role

16. Collaborative care
“If physicians view themselves as experts whose job is to get patients to behave in ways that reflect that expertise, both will continue to be frustrated…Once physicians recognize patients as experts on their own lives, they can add their medical expertise to what patients know about themselves to create a plan that will help patients achieve their goals.”
Funnell & Anderson JAMA 2000;284:1709

17. How to emphasize the patient’s role
•Simple messages from the primary care provider:
–“Diabetes is a serious condition. There are things you can do to live better with diabetes and things the medical team can do to assist you. We are going to work together on this.”
•Consistent approach
•Culturally and linguistically appropriate

18. Self Management Support: Core Clinical Competencies
(New Health Partnerships, 2007)
•Relationship Building
•Exploring patients’ needs, expectations and values
•Information Sharing
•Collaborative Goal Setting
•Action Planning
•Skill Building & Problem Solving
•Follow-up on progress

19. Motivational Interviewing
“a skillful clinical style for eliciting from patients their own motivation for making changes in the interest of their health.”
(Rollnick, Miller and Butler, Motivational Interviewing in Health Care, 2008)

20. “Spirit of Motivational Interviewing”
(Rollnick, Miller and Butler, Motivational Interviewing in Health Care, 2008)
•Collaborative
•Partnership, shared decision making
•Evocative
•Understand patient goals; evoke arguments for change
•Honoring patient autonomy
•Patients ultimately decide what to do

21. Motivational Interviewing
“Principles”
•Resist the Righting Reflex (Directing)
•Understand Patient Motivations
•Listen to Your Patient with Empathy
•Empower Your Patient
(Rollnick, Miller and Butler, Motivational Interviewing in Health Care, 2008)

22. Explore: Agenda, Needs, Expectations
“What are you hoping to accomplish today?”
“What do you think is most important for us to talk about?”
What concerns do you have about your health?
What reasons do you have to change?
Where would you like to start?

23. Self-management skills for patients
Five areas of self-care – some ideas to get started
Information
Skills and knowledge training
Tools and self-monitoring devices
Healthy lifestyles choices
Support networks

24. Action Planning – Starts with SMART Goals
•Specific and behavioral
•Measurable
•Attractive
•Realistic
•Timely

25. Action Plan
1. Goals: Something you WANT to do
2. Describe
How Where
What Frequency
When
3. Barriers -
4. Plans to overcome barriers -
5. Conviction and Confidence ratings (0-10) -
6. Follow-Up:

26. Action Plan
1. Goals: Something you WANT to do Begin Exercise
2. Describe
How Walking Where Neighborhood
What 20 min Frequency 3x/week
When After dinner
3. Barriers - Dishes, safety (no sidewalks)
4. Plans to overcome barriers - get kids to clean up, ask neighbor or husband to join me, wear reflective vest
5. Conviction and Confidence ratings (0-10) - 9/8
6. Follow-Up: Will keep log and bring to next visit in 1 month

27. Action Planning
•Review past experience - especially successes
•Define small steps that are likely to lead to success

28. “How confident are you that you can meet your goal of exercising 5 days a week?
Not at all confident
Totally
confident
0 1 2 3 4 5 6 7 8 9 10
Action Planning:
Assess and Enhance Confidence
“What makes you say 6?
“What might help you to get to a 7 or 8?”
“What could I do to help you to feel more confident?”
(From Keller and White, 1997; Rollnick, Mason and Butler, 1999)

29. Enhancing Confidence
•Provide tools, strategies, resources, skills
•Address barriers
•Attend to progress and to perceive slips as occasions for problem solving rather than as failure

30. Enhancing Confidence:
Identifying Barriers & Problem-Solving
• What will get in the way?
• Anything else?
• What might help you to overcome that barrier?
• Anything help in the past?
• Here is what others have done...
• Ok, now what is your plan?
• Reassess confidence

31. Self-Management Support Cycle
Adapted from: Glasgow RE, et al (2002) Ann Beh Med 24(2):80-87
EXPLORE :
Needs, Expectations, Values,
Behavior, Progress
SHARE : Provide specific Information about health risks, benefits of change, and strategies to self- manage
SET GOALS: Collaboratively set goals based on patient’s conviction and confidence in their ability to change
BUILD SKILLS : Identify personal barriers, strategies, problem-solving techniques and social/environmental support
ARRANGE :
Specify plan for
follow-up (e.g., visits,
phone calls, mailed
reminders
Personal Action Plan 1. List specific goals in behavioral terms 2. List barriers and strategies to address barriers 3. Specify follow-up plan 4. Share plan with practice team and patient’s social support

32. Opportunities for Self Management Support:
When, Where and By Whom
 Before the Encounter
 During the Encounter
 After the Encounter

33. Opportunities for SMS
Before the Encounter
•Pre-visit contact (phone, mail or e-mail)
•Waiting room assessment
•Patient education material
•Posters
•Pamphlets on “Talking to Your Provider”
•Community outreach

34. Opportunities for SMS
During the Encounter
•Review assessments
•
•Feedback on achievements vs. goals
•Identifies priorities for visit
•5 “A”s Counseling
•Targeted patient education materials
•Referral for more SMS

35. Opportunities for SMS
After the Encounter
• Referrals (Health Education, etc)
• Further 5 “A”s counseling
• Phone calls follow-up
• Mailed patient education
• Peer support
• Newsletters
• Follow-up visits
• e-mail/Internet sites

36. Implementing Health System Changes to Support Self-Management
•Quality Improvement Collaboratives: IPIP/PCMH Collaborative
•Educational Outreach – QIOs (CCME), AHEC, CCNC
•Provider education and training - Core Competencies, Motivational Interviewing
•Incentives, rewards for provider delivery of SMS, system change

37. SELF MANAGEMENT AND HOW IT RELATES TO PCMH STANDARD 4

38. PCMH Standard 4 Provide Self-Care Support and Community Resources
Element A : Support Self-Care Process
Element B : Provide Referrals to Community Resources

39. PCMH Standard 4 Element A: Support Self-Care Process
•Provides education resources or refers at least 50% of patients to educational resources to assist in self- management
•Uses an EHR to identify patient-specific education resources
•Develops and documents self-management plans and goals
•Documents self-management abilities for al least 50% patients
•Provides self- management tools to record self-care results for at least 50%
•Counsels at least 50% of patients/families to adopt healthy behaviors
The practice conducts activities to support patients/families in self-management.

40. PCMH Standard 4 Element B: Provide Referrals to Community Resources
•Maintains a current resource list on five topics
•Tracks referrals provided to patients/families
•Arranges or provides treatment for mental health and substance abuse disorders
•Offers opportunities for health education programs (such as group classes and peer support)
The practice supports patients/families that need access to community resources:

41. Resources for Implementing Self-Management
Self-Management Support: A Toolkit for Clinicians http://www.improvingchroniccare.org/downloads/partnering_in_selfmanagement_support__a_toolkit_for_clinicians.doc Primary Care Resources and Support for Chronic Disease and Self-Management http://improveselfmanagement.org/index.aspx Improving Your Practice Manual - Improving Chronic Care, 2005 www.improvingchroniccare.org/index.php?p=Steps_for_Improvement&s=37 Primary Care Resources and Support for Chronic Disease and Self-Management http://improveselfmanagement.org/index.aspx Improving Your Practice Manual - Improving Chronic Care, 2005 www.improvingchroniccare.org/index.php?p=Steps_for_Improvement&s=37

42. Questions??