Practice Facilitation Handbook

Table 21.1. Self-management support tasks and assignments

Task Primary Care Clinician Nurse/ Pharmacist Medical Assistant Clinical Care Manager Nutritionist/ PT, OT Health Educator/ Dietitian Clerical Staff & Other
Call patient in for visit              
Plan patient visit              
Introduce SMS and patient role              
Develop action plan with patient              
Educate and train patient              
Confirm patient understanding              
Refer patient to community resources              
Schedule followup visits              
Conduct followup with patient between visits              
Establish referral and information sharing protocols with community SMS programs              
Maintain inventory of patient education materials              
Maintain inventory of community resources              
Identify SMS-related training opportunities for staff              
Collect and report on SMS performance measures              

Adapted from IHI

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Page last reviewed May 2013
Internet Citation: Table 21.1. 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/tab21.1.html