AHRQ's Prevention and Chronic Care Program has developed a library of resources and videos that aims to help clinicians learn more about this concept. Please visit http://www.ahrq.gov/professionals/prevention-chronic-care/improve/self-mgmt/self/sms_home.html to access these resources.
Self-management support goes beyond simply supplying patients with information. It includes a commitment to patient-centered care, providing clear and useful information to patients, helping patients set goals and make plans to live a healthier life, creating a team of clinicians and administrative staff with clearly understood roles and responsibilities, and using office systems to support followup and tracking of patients.
Self-management support includes the following:
- Providing compassionate, patient-centered care
- Involving the whole care team in planning, carrying out, and following up patient visits
- Planning patient visits that focus on prevention and care management rather than critical or acute care
- Involving the patient in goal setting
- Providing customized education and skills training, using materials appropriate for different cultures and health literacy levels
- Making referrals to community-based resources, such as programs that help patients quit smoking or follow an exercise plan
- Following up with patients through email, phone, text messaging, or mailings to support them taking good care of themselves
Why Is Self-Management Support Important?
Managing chronic illness and changing behavior are challenging and take time for everyone involved—providers, patients, and caregivers. Yet, it is often patients themselves who are called on to manage the broad range of factors that contribute to their health. Common sense suggests—and health care experts agree—that people with chronic care needs should receive support to help them manage their health as effectively as possible. Using self-management support in primary care can have a positive effect on the care and health outcomes of people with chronic conditions, as well as provider and patient satisfaction.
Helping patients to make good choices and maintain healthy behaviors requires a collaborative relationship between the primary care clinical team and patients and their families. Learning how to incorporate self-management support into practice can support patients in building the skills and confidence they need to lead healthier lives.
How Can Self-Management Support Be Put Into Action?
Incorporating self-management support into the daily routine of clinical practice can be challenging, but there are many helpful programs and resources available, including the following specific strategies.
Defining and sharing the roles and responsibilities of the practice care team. To provide effective self-management support, a team of clinicians and administrative staff need to coordinate closely with each other to provide care before, during, and after the patient visit. Successful teams are made up of clinical and administrative staff whose roles are planned in advance. Some roles and responsibilities include:
- Gathering clinical data before a visit
- Setting agendas for the visit
- Helping patients set health goals
- Developing action plans for achieving goals
- Tracking health outcomes
- Referring patients to community programs
- New Health Partnerships' Partnering in Self-Management Support: A Toolkit for Clinicians
- American Academy of Family Physicians' A New Approach to Group Visits: Helping High-Need Patients Make Behavioral Change
Using tools and techniques to improve self-management support. Self-management support includes a variety of techniques and tools that help patients choose and maintain healthy behaviors. Primary care staff can ease into a self-management support program by learning how to use tools such as action plans, goal-setting worksheets, and problem solving techniques to support and motivate patients.
- California HealthCare Foundation's Helping Patients Help Themselves: How to Implement Self-Management Support
- California HealthCare Foundation's Coaching Patients for Successful Self-Management
- American Academy of Family Physicians' Improve Care With Patient Self-Management Support
- American Medical Association's Self-Management Strategies for Vulnerable Populations
Learning new skills, such as motivational interviewing and reflective listening. The best use of self-management support is the collaborative interaction between the clinician and the patient. Motivating, listening, and coaching are important self-management support skills that can make the clinician-patient interaction stronger and in which all members of the care team can become knowledgeable. Through ongoing training and practice, supporting patients and their families in self care will become part of day-to-day care.
- American Medical Association's Motivating Patients to Change Behavior
- American Academy of Family Physicians' Have You Really Addressed Your Patient's Concerns?
Selecting understandable, actionable educational materials and using them effectively. Many print and audiovisual educational materials do not communicate effectively. Handing out even well-designed materials is not likely to promote patient self-management. Primary care staff can start by choosing materials that diverse patients can understand and act on, and then reviewing the material with the patient and confirming understanding.
- The Patient Education Materials Assessment Tool (PEMAT) and User's Guide.
- Health Literacy Universal Precautions Toolkit (e.g., Tool 12: Use Health Education Material Effectively).
- Medline Plus in Multiple Languages.