Patient Self-Management Support of Chronic Conditions: Framework for Clinicians Seeking Recertification Credit (MOC Part IV & PI-CME)

AHRQ presents the following suite of quality improvement resources for clinicians to earn recertification credit and pursue quality improvement (QI) efforts of interest to them.


Free, Self-contained Framework for Clinicians to Design Their Own QI Project. Using this module, clinicians can improve how they support their patients’ ability to self-manage chronic Conditions—Physicians, nurse practitioners, and PAs select chronic condition of interest to them (arthritis, asthma, COPD, depression, diabetes, heart disease, obesity/overweight) and enhance their skills for helping patients with chronic conditions while improving the patient experience. The easy-to-complete QI activity provides: step-by-step instructions and framework for the design and documentation of the QI project of interest to a clinician. Clinicians will survey how patients/parents have experienced the clinicians’ use of two self-management support techniques: 1. shared decisionmaking about prescription medications (when and if appropriate), and 2. talking about patients’ specific health goals. The clinician will then design and implement a rapid-cycle QI activity of interest to the clinician/practice using validated CAHPS QI measures. SMS resources for some chronic conditions, such as asthma and obesity, are appropriate for both pediatric and adult patients. Download the User Guide and interactive PDF file to your own computer for data collection and processing. We encourage yet do not require clinicians to work together to design and discuss impact of the quality improvement intervention program (Learn more below: Practices Can Help Clinicians Work Together to Complete Recertification Projects.)

User Guide (PDF—1.54 MB)—Provides navigation and submission instructions for clinicians to receive Board-specific recertification credit: MOC Part IV (ABP and ABFM); PI-CME (PAs); and (forthcoming, summer 2016) CE credit for related Webinar material (NPs). The User Guide is current as May 12, 2016. Note: the American Board of Internal Medicine (ABIM) discontinued its Self-Directed Practice Improvement Module (PIM) program in late January 2016. Before beginning the module, you may wish to check to see if your Board has made any changes to its requirements.

Interactive PDF (PDF—5.37 MB)—To be stored on clinician's own computer system, where the clinician selects appropriate certification Board(s) and complete data entry. Includes hyperlinked resources about patient self-management support, quality improvement cycles, evaluation metrics and methods, and practice approach to quality improvement.

  • This interactive PDF must be downloaded to your computer and opened in Adobe Acrobat Reader to function properly. To do that, right click (Windows) or hold Control and click (Mac) on the link to the PDF, then choose the option that says "Save this target as" (Windows) or "Download linked file as" (Mac). Choose a location on your computer to save the file, then open the file from that location. To ensure the PDF opens with Acrobat Reader, right click the file and select "Reader" from the "Open with" choices.
  • To use a screen reader application with this module, please change your Acrobat reading preferences under the Screen Reader Options to "Only read the currently visible pages." Then close and reopen the PDF; you do not have to download it again. Instructions on how to change the setting are in Accessing PDF Documents with Assistive Technology. If you have difficulty after changing your assistive technology settings or need help making the changes, contact our technical assistance number at 301-427-1600. Please specify the module you are trying to use and the nature of your concern.
  • Coming late summer 2016, AANP-CE credit for nurse practitioners who complete the AHRQ-generated webinar, Overview: Self-Management Support for Patients with Chronic Conditions,

SMS Resources (PDF – 1.1 MB)— Provides links to external resources identified throughout the module in one document. The identified resources are separated into two categories: one for Clinicians and Staff and another for Patients and Families. This guide also identifies tools that target specific chronic conditions, such as asthma, COPD, depression, diabetes, heart disease, and overweight/obesity. Examples of a Self-Management Goal Worksheet for Patients and a Shared Decisionmaking Checklist are also included in this guide.

AHRQ presented two Webinars to enable clinicians to confer with one another as they complete the Patient Self-Management Support Quality Improvement Project. These Webinars were designed to complement each other. Part one of the Webinar series, Overview: Self-Management Support for Patients with Chronic Conditions was held on June 30, 2016, and part two was held on July 28, 2016.

June 30, 2016, "Self-Management Support for Patients with Chronic Conditions: Clinicians Confer about Recertification QI Module (MOC Part IV & PI-CME)”

AHRQ’s easy-to-complete recertification project, “Patient Self-Management Support: A Chronic Conditions Practice Improvement Activity,” fosters clinicians’ capacity to document patient self-management support—such as asking about health goals—in patients’ medical records (paper or electronic). In an effort to assist clinicians (MOC Part IV credit for physicians and PI-CME for PAs) to transition from individual quality improvement recertification exercises into sustainable quality improvement enterprise, AHRQ and CDN hosted a two-part virtual classroom for this project. This free, Web-based meeting (offered live and, subsequently, as a recording) provided an overview of patient self-management support and offered diversified clinicians an opportunity to discuss THEIR strategies. This webinar is appropriate for clinicians serving both pediatric and adult populations. Select here for a recording of the webinar.

July 28, 2016, "Clinicians and Practice Managers confer on Lessons from Self-Management Support Projects for MOC IV and PI-CME (for PAs)"

Clinicians and practice managers discuss their findings and plans for sustaining this QI effort.

Strategies for coordinated clinicians’ completion of two complementary recertification modules in order to meet Required MOC Part IV Points for recertification will be discussed:

Please review this 1-hour webinar discussion, hosted by AHRQ and CDN, about starting or completing the education module, “Patient Self-Management Support: A Primary Care Practice Improvement Activity.” This webinar is a followup to the “Part 1: Prepared Clinicians Confer on Strategies to Complete Patient Self-Management Support MOC IV and PI-CME (for PAs)” held in late June.  This clinician-led, web-based meeting (offered live and, subsequently, as a recording), offered diversified clinicians an opportunity to discuss THEIR project findings and plans for sustaining this Quality Improvement effort. Select here for a recording of the webinar.

Practices Can Help Clinicians Work Together to Complete Recertification Projects (PDF - 2.6 MB)—Diversified clinician groups—physicians, physician assistants, and nurse practitioners—can work together in quality/practice improvement at the practice level to realize greater satisfaction and sustained impact of quality improvement pursuits. This document highlights potential synergy between organizations' current infrastructure and otherwise disparate clinicians' pursuit of recertification requirements.

Page last reviewed June 2019
Page originally created May 2016
Internet Citation: Patient Self-Management Support of Chronic Conditions: Framework for Clinicians Seeking Recertification Credit (MOC Part IV & PI-CME). Content last reviewed June 2019. Agency for Healthcare Research and Quality, Rockville, MD.