Practice Facilitation Handbook
Module 21. Improving Self-Management Support
An individual with chronic disease is in the medical office an average of 6 hours a year. The patient spends the remaining 8,754 hours a year outside the medical office. Self-management support is about helping patients improve or maintain their health during those 8,754 hours.
Self-management is the patient’s ability to deal with everything that having a chronic condition entails, including symptoms, treatment, emotional impact, physical and social consequences, and lifestyle changes. It also includes patients’ beliefs in their ability to overcome or manage their conditions, their ability to navigate and interact effectively with clinicians and the health care system to ensure they receive needed care, and the behaviors they engage in to manage their conditions and their care.
An increasing number of people have at least one chronic illness that requires day to day management. Outcomes for these patients with chronic needs can be improved by helping them become more active in self care.
–Agency for Healthcare Research and Quality
What Self-Management Challenges Do Safety Net Patients Face?
A significant percentage of individuals who receive care through the safety net have chronic conditions. These individuals face special challenges to self-management. Low levels of health literacy can make it difficult for patients to understand instructions provided by clinicians about caring for their conditions. The perceived power differential between clinicians and patients can make it difficult for patients to ask questions or effectively advocate for their care. Norms of different cultural groups that view questions or engagement of clinicians as disrespectful also can inhibit effective communication.
Poverty and lack of insurance reduce access to needed specialty care services and medications. Patients’ adherence to treatment recommendations can be affected by inaccurate stories and myths in the patient community about treatments such as insulin, resulting in amputations and death. Similarly, patients’ views of illness in general and their ability to influence its course can be shaped by cultural norms that suggest an inevitability of outcome, inhibiting the patients’ willingness to engage in what may be perceived as futile attempts at self-care.
Behaviors essential to healthy living may also be affected by cultural traditions, as well as the overabundance of fast foods and limited access to healthy low-cost foods and safe spaces for exercise in low-income neighborhoods. Social cohesion and support, vital to effective management of chronic conditions, may be compromised by fear. High crime rates and immigration enforcement actions can wreak havoc on social networks and support available to individuals living with chronic illness and their families.
How Can Practices Provide Self-Management Support?
In 2003, the Institute of Medicine defined self-management support as “the systematic provision of education and supportive interventions by health care staff to increase patients’ skills and confidence in managing their health problems, including regular assessment of progress and problems, goal setting, and problem-solving support.” Although in the early days self-management support primarily consisted of providing information, research has demonstrated that these educational interventions affected patients’ knowledge but not their self-care behavior (Pearson, et al., 2007).
Coaching is needed by professionals who, in addition to teaching skills, have the psychosocial skills to facilitate a patient’s change in behavior. Evidence is emerging that self-management support programs, which now often include an interactive, empowerment approach, improve a variety of outcomes for different chronic conditions (Pearson, et al., 2007).
Practices provide self-management support to patients in a variety of ways. According to the Agency for Healthcare Research and Quality (AHRQ), these include:
- Providing empathic, patient-centered care.
- Involving the whole care team in planning, carrying out, and following up on a patient visit.
- Planning patient visits that focus on prevention and care management, rather than on acute care.
- Involving the patient in goal setting.
- Providing tailored 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.
- Regularly following up with patients via e-mail, phone, text messages, and mailings to support their efforts to maintain healthy behaviors.
Self-management support is a core feature of the Care Model and fundamental to the provision of patient-centered care. Effective self-management support, however, can be time intensive. Fortunately, self-management support programs are often offered in the community and can be used to augment practice staff activities.
Practices usually combine some in-house self-management support activities with referrals to community-based resources. Practices using this approach will need to identify and vet these community-based programs. At a minimum, a self-management program should be evidence based, linguistically competent (meaning they are delivered in the preferred language of the patient), appropriate to the health literacy level of the patient, and culturally sensitive and appropriate.
How Can Facilitators Help?
As a facilitator, you can help practices with a variety of self-management support tasks, such as:
- Assessing existing self-management support services.
- Mapping current roles and workflows related to self-management and helping the practice redesign them.
- Setting goals to improve these services.
- Using the Model for Improvement to design and test improvements to services (see Module 4, Approaches to Quality Improvement).
- Identifying appropriate patient self-management support materials.
- Identifying self-management support training and resources for clinicians and other staff (e.g., AHRQ’s Self-Management Support Resource Library).
- Introducing and training staff on evidence-based and exemplar self-management support programs.
- Conducting an inventory of community-based programs.
- Developing referral relationships and protocols with community-based programs (see DeWalt, et al., 2010, Health Literacy Universal Precautions Toolkit, Tool 20, Use Health and Literacy Resources in the Community).
- Establishing followup routines to check in with patients between visits.
- Setting up performance reporting for monitoring the delivery and impact of these services.
Self-management support involves the entire care team. As shown in Module 19, you can help your practice think through the various tasks involved in self-management support (SMS) and which staff members could perform those tasks. Table 21.1, adapted from the Institute for Healthcare Improvement, gives you a template to work from. You and your practices will need to customize the list of tasks and staff.
Agency for Healthcare Research and Quality. Self Management Support. Available at: http://www.orau.gov/ahrq/sms_home.html. Accessed April 12, 2013.
DeWalt DA, Callahan LF, Victoria H. Hawk, et al. Health literacy universal precautions toolkit. Rockville, MD: Agency for Healthcare Research and Quality; 2010. AHRQ Publication No 10-0046-EF. Available at: http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/. Accessed April 12, 2013.
Pearson ML, Mattke S, Shaw R, et al. Patient self-management support programs: an evaluation. Final Contract Report (Prepared by RAND Health under Contract No. 282-00-0005). Rockville, MD: Agency for Healthcare Research and Quality; November 2007. AHRQ Publication No. 08-0011.