Module 21 Appendix

Self-Management Support Tasks and Assignments

Role Visualization Exercise for Self-Management Support

Complete the chart by describing what each team member will do for each of the listed tasks for self-management support. Not all team members will be involved in each activity, nor is the list of tasks exhaustive.

RolePCPNurseMAClinical Care ManagerDietitian/PT/OTAdministrative Staff/Patient NavigatorOther
Introduce SMS, describe roles       
Set visit agenda       
Collaborate on patient goal setting       
Provide information and skills training to patients       
Create an Action Plan       
Connect patients with resources in community and elsewhere in health system       
Oversee disease registry/ proactive followup       
Conduct previsit chart reviews       

Adapted with permission from Institute for Healthcare Improvement, Cambridge, MA.

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Current as of May 2013
Internet Citation: Module 21 Appendix: Self-Management Support Tasks and Assignments. May 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod21appendix.html