Self-Management Support Resource Library

Resource Type:

The library resources below are linked to the resources they describe, or to abstracts of those resources.  Although abstracts are limited, the full-text resource can be obtained from the cited source.

SMS Articles

Articles include those written for publication, whether for an academic journal or professional organization publication, in PDF or Web page format.

Title Source Summary
2-sided Assessment and Targeted Messages Tool
(PubMed abstract)
Clinical Pediatrics

Citation: Woolford SJ, Clark SJ, Ahmed S, et al. Feasibility and acceptability of a 1-page tool to help physicians assess and discuss obesity with parents of preschoolers. Clin Pediatr 2009;48(9):954-9.

This research article summarizes the feasibility and acceptability of a one-page obesity prevention and treatment tool for clinicians to use with parents of preschoolers. The tool contains assessment and recommendations for treatment. Assessment items pertain to nutrition, physical activity, family history, physical exam, and readiness and confidence of parents to make dietary and activity changes in their child's life. Recommendations include behavior change suggestions and action steps for the child's care over the ensuing 3-6 months. This article presents findings of a study in which pediatricians were surveyed about the tool.
A 'Stages of Change' Approach to Helping Patients Change Behavior American Academy of Family Physicians

Citation: Zimmerman GL, Olsen CG, Bosworth MF. A 'stages of change' approach to helping patients change behavior. Am Fam Physician 2000;61(5):1409-16.

This article from the American Academy of Family Physicians explains the Stages of Change model and its application in clinical settings. It includes an assessment tool to measure a patient's readiness to change a specific health behavior.
Have You Really Addressed Your Patient's Concerns?
(PDF file)
Robert Wood Johnson Foundation

Citation: Epstein RM, Mauksch L, Carroll J, et al. Have you really addressed your patient's concerns? Fam Pract Manag. 2008;15(3):35-40.

This article from Family Practice Management offers clinicians strategies for creating interactions with patients that ensure patient concerns are voiced and addressed collaboratively. It includes examples of conversations that are patient-centered versus those that are physician-dominated. In addition, the article outlines steps for collaborative agenda setting.
Helping Patients Take Charge of Their Chronic Illnesses American Academy of Family Physicians

Citation: Funnell, MM. Helping patients take charge of their chronic illnesses. Fam Pract Manag. 2000;7(3):47-51.

This article from the American Academy of Family Physicians introduces Self-Management Support (SMS) concepts, provides a rationale for patient self-management, and gives an example of how to empower patients with information. It makes a case for shifting from an acute care model to a patient-centered care model that includes SMS.
Implementing Practical Interventions to Support Chronic Illness Self-Management
(PubMed abstract)
Joint Commission Journal on Quality and Safety

Citation: Glasgow RE, David CL, Funnell MM, et al. Implementing practical interventions to support chronic illness self-management. Jt Comm J Qual Saf 2003;29(11):563-74.

This article compares the current physician-centered philosophies that are prevalent in clinical settings with the patient-centered approach that focuses on actively integrating evidence-based Self-Management Support (SMS) throughout a patient's clinical experience. It makes the case for why clinical practices should change while acknowledging and addressing some of the barriers to providing SMS. The article outlines the behaviors and attitudes of clinicians who have successfully implemented a patient-centered approach in their practices.
Patient Self-Management of Chronic Disease in Primary Care
(PubMed abstract)
Journal of the American Medical Association

Citation: Bodenheimer T, Lorig K, Holman H, et al. Patient self-management of chronic disease in primary care. JAMA 2002;288(19):2469-75.

This research article summarizes evidence from clinical trials on patient self-management skills and self-management programs that show improved patient outcomes and reduced health care costs.
Self-Management Aspects of the Improving Chronic Illness Care Breakthrough Series: Implementation with Diabetes and Heart Failure Teams
(PubMed abstract)
Annals of Behavioral Medicine

Citation: Glasgow RE, Funnell MM, Bonomi AE, et al. Self-management aspects of the improving chronic illness care breakthrough series: implementation with diabetes and heart failure teams. Ann Behav Med 2002;24(2):80-7.

This journal article describes endeavors to integrate Self-Management Support into health care systems through systems change and staff training in the Chronic Illness Care Breakthrough Series. It presents data on teams from 21 participating health care systems over a 13-month period, offers lessons learned, and provides suggestions for future research and practice.
Self-Management Education: History, Definition, Outcomes, and Mechanisms
(PubMed abstract)
Annals of Behavioral Medicine

Citation: Lorig KR, Homan HR. Self-management education: history, definition, outcomes, and mechanisms. Ann Behav Med 2003;26(1):1-7.

This article from the Annals of Behavioral Medicine provides a brief history of self-management, offers evidence of its effectiveness, explains three self-management tasks (medical management, role management, emotional management), defines six self-management skills (problem solving, decision making, resource utilization, formation of patient-provider relationship, action planning, self-tailoring), and explores common problems and solutions associated with self-management support integration.
Self-Management Education Programs in Chronic Disease
(PubMed abstract)
Archives of Internal Medicine

Citation: Warsi A, Wang PS, LaValley MP, et al. Self-management education programs in chronic disease: a systematic review and methodological critique of the literature. Arch Intern Med 2004; 64(15):1641-9.

Systematic review of self-management education programs for various chronic diseases in an attempt to evaluate their efficacy and assess whether specific features of these programs were associated with improved clinical outcomes.
Supporting Self-Management in Patients with Chronic Illness American Academy of Family Physicians

Citation: Coleman MT, Newton KS. Supporting self-management in patients with chronic illness. Am Fam Physician. 2005; 72(8):1454, 1456.

This article on self-management support (SMS) includes a brief literature review, methods and steps for incorporating SMS in a clinical practice, and tools such as action plans and "stoplight" tools that can be used to implement SMS.

SMS Guides

Guides provide detailed information on a specific improving primary care topic. They might provide "how to" information on implementing processes or systems in a clinical setting. Guides may be lengthier than many of the other resource types and may be presented as a booklet.

Title Source Summary
AMA Healthier Life Steps: Physician's Guide to Patient Screening, Intervention, and Motivation Tools and Techniques
(PDF file)
American Medical Association

Citation: American Medical Association. Physicians' Guide: Patient Screening, Intervention and Motivation Tools and Techniques. Accessed Feb. 12, 2016.

The AMA Healthier Life Steps program is a resource that includes patient self-assessments and action plans that can be used in a clinical setting. This Physician's Guide provides answers to common questions clinicians may have while implementing the Healthier Life Steps program in their practices.
Building Peer Support Programs to Manage Chronic Disease: Seven Models for Success California HealthCare Foundation

Citation: Heisler M. Building Peer Support Programs to Manage Chronic Disease: Seven Models for Success. Oakland: California HealthCare Foundation; 2006.  Accessed Feb. 12, 2016.

This report by the California HealthCare Foundation describes seven models of peer support to include in self-management support (SMS) programs. Models include group visits, peer-led SM training, peer coaches, community health workers, support groups, telephone-based peer support, and Web and e-mail programs. For each model, the report provides a case study and considerations for costs and reimbursement. The report concludes with recommendations on implementation and evaluation of peer support interventions. PDF version available.
Helping Patients Help Themselves: How to Implement Self-Management Support California HealthCare Foundation

Citation: Helping Patients Help Themselves: How to Implement Self-Management Support. Bodenheimer T, Abramozwitz, S. 2010. Oakland: California HealthCare Foundation.  Accessed Feb. 12, 2016.

This paper from the California HealthCare Foundation defines self-management support (SMS), provides case studies of primary care practices that have implemented SMS, and discusses the business case for SMS. Case studies include settings such as primary care practices, behavioral health programs, and telephone consultations. Case studies feature SMS models that rely on the actions of nurses, medical assistants, community health workers (promotoras), and health coach volunteers. PDF version available.
Helping Patients Manage Their Chronic Conditions
 
California HealthCare Foundation

Citation: California HealthCare Foundation. Helping Patients Manage Their Chronic Conditions.  Accessed Feb. 12, 2016.

This report contains evidence in favor of providing self-management support (SMS) to patients in clinical settings. It offers an explanation of five SMS strategies: establishing an agenda, "ask-tell-ask", closing the loop, assessing readiness to change, and goal setting. In addition, the report provides a literature review on SMS techniques and outcomes. PDF version available.
Sharing the Care: The Role of Family in Chronic Illness California HealthCare Foundation

Citation: Sharing the Care: The Role of Family in Chronic Illness. Rosland A. August 2009. California HealthCare Foundation. Accessed Feb. 12, 2016.

This report provides background information, experience-based insights, family intervention program case examples, and resources to help those interested in supporting family involvement in chronic care management. It is based on a review of published medical literature, general Web searches, and program developer and researcher expertise in the fields of social support and family involvement in chronic illness care. PDF version available.

SMS Materials for Patients

Materials for Patients include information to be seen by or given to patients, such as worksheets to help prompt health behavior discussions with clinicians or educational handouts that patients could take home.

Title Source Summary
Healthy Men (Tips for Consumers & Patients) Agency for Healthcare Research and Quality This Web page helps men learn how to stay healthy, talk with their doctors, get preventive screenings, be aware of their medications, and find additional information.
Questions Are the Answer (Tips for Consumers and Patients) Agency for Healthcare Research and Quality This Web page provides information for patients on how to get better care by asking their clinicians questions about their health and care. The page includes video links and a question list builder.
Conozca las preguntas (en Español) Agency for Healthcare Research and Quality A menos que estén muy enfermos, muchos hispanos piden a sus amigos, compañeros de trabajo, e incluso conocidos casuales asesoría para tratar sus problemas médicos.
Care Planning (Tips for Consumers & Patients) Agency for Healthcare Research and Quality Learn about costs of health care, choosing health care plans, and preventing errors.
Diagnosis & Treatment (Tips for Consumers & Patients) Agency for Healthcare Research and Quality Information for Patients and Consumers about getting diagnosed, having surgery, taking medications and having treatments, and using hospitals and clinics.
Prevention & Health (Tips for Consumers & Patients) Agency for Healthcare Research and Quality The latest evidence-based information for improving your health.

SMS Reports

Documents that detail projects that have been undertaken, identify trends, describe case studies, or communicate meeting and expert panel findings. Reports may be generated by a government agency.

Title Source Summary
Patient Self-Management Support Programs: An Evaluation Agency for Healthcare Research and Quality

Citation: Pearson ML, Mattke S, Shaw R, Ridgely MS, Wiseman SH. Patient Self-Management Support Programs: An Evaluation. Final Contract Report (Prepared by RAND Health under Contract No. 282-00-0005). AHRQ Publication No. 08-0011. Rockville, MD: Agency for Healthcare Research and Quality; November 2007.

This Agency for Healthcare Research and Quality report investigates the issues that decision makers should examine when designing a self-management support (SMS) system for their healthcare facilities. It lists key findings and recommendations for creating SMS programs based on an extensive literature review.  PDF version available.
Promoting Effective Self-Management. Approaches to Improve Chronic Disease Care: Lessons Learned California HealthCare Foundation

Citation: Kanaan SB. Promoting Effective Self-Management Approaches to Improve Chronic Disease Care: Lessons Learned. Oakland: California HealthCare Foundation; 2008. Accessed Feb. 12, 2016.

This report from the California HealthCare Foundation summarizes the lessons learned by 10 grantee health care organizations that integrated self-management support into their structures and processes for diabetes care. Changes include system redesign, patient flow, staff training, and measurement. PDF version available.
Also available: My Diabetes Plan (English, PDF file) and
Mi plan de acción para controlar la diabetes (Spanish, PDF file)

SMS Tools

Tools can include tip sheets, evaluation materials, and toolkits on specific topics. Tools can be used by clinicians, administrators, researchers, and evaluators to help them improve patient care. This resource type does not include resources that are given to or seen by patients (see Materials for Patients).

Title Source Summary
A New Approach to Group Visits: Helping High-Need Patients Make Behavioral Change American Academy of Family Physicians

Citation: Antonucci J. A New Approach to Group Visits: Helping High-Need Patients Make Behavioral Change Fam Pract Manag 2008;15(4):A6-A8.

This brief article explains why and how one physician began offering group visits to patients who face similar challenges managing their chronic conditions. The author provides information on how to bill for group visits and describes some of the behavior changes she has seen in the participating patients.
AHRQ Health Literacy Universal Precautions Toolkit, 2nd edition Agency for Healthcare Research and Quality

Citation: Brega AG, Barnard J, Mabachi NM, Weiss BD, DeWalt DA, Brach C, Cifuentes M, Albright K, West, DR. AHRQ Health Literacy Universal Precautions Toolkit, Second Edition. (Prepared by Colorado Health Outcomes Program, University of Colorado Anschutz Medical Campus under Contract No. HHSA290200710008, TO#10.) AHRQ Publication No. 15-0023-EF. Rockville, MD. Agency for Healthcare Research and Quality. January 2015.

This toolkit can help primary care practices reduce the complexity of health care, increase patient understanding of health information, and enhance support for patients of all health literacy levels. Self-management support tools include:

PDF version available

Assessment of Primary Care Resources and Supports for Chronic Disease Self-Management
(PDF file)
Robert Wood Johnson Foundation

Citation: Assessment of Primary Care Resources and Supports for Chronic Disease Self Management. Copyright 2006 Washington University School of Medicine, with support from the Robert Wood Johnson Foundation, Princeton, NJ. Accessed Feb. 12, 2016.

This survey-based, quality improvement tool allows a clinical team to self-assess its level of self-management support (SMS) implementation for specific cohorts of patients. The tool is designed so that the clinical team can review and discuss the results in order to improve future SMS services. The survey can be conducted at regular intervals to measure improvement in the SMS offered by the team.
The tool can be accessed without registration, but to use the interactive accompanying features, users need to create an account and login to the website.
Partnering in Self-Management Support: A Toolkit for Clinicians
(PDF file)
Institute for Healthcare Improvement

Citation: Institute for Healthcare Improvement. Partnering in Self-Management Support: A Toolkit for Clinicians. Accessed Feb. 12, 2016.

The concepts and tools in this toolkit are intended to give busy clinical practices an introduction to a set of activities and changes that support patients and families in the day-to-day management of chronic conditions. More than a dozen tools and resources are available for experienced teams and practices that are just beginning to reorganize for patient-centered care.

The toolkit combines information on how to create a continuous self-management support (SMS) cycle in a clinical practice. It outlines the steps for creating a practice that provides SMS to patients before, during, and after each visit. For each step, the toolkit offers tips on communicating with patients and lists numerous links to related resources.

Link to full toolkit (requires log in)

Link to PDF version only.

Physician Tip Sheet For Self-Management Support American Medical Association

Citation: American Medical Association. Physician Tip Sheet for Self-management Support. Accessed Feb. 12, 2016.

This tip sheet can be used by clinicians trained in self-management support (SMS) as a quick review or handy reference material for engaging patients in effective self-management conversations. Once clinicians have a good understanding of SMS, it can be used as review or reminder material. PDF version available.
Self-Management Toolkit South West Local Health Integration Network

Citation: South West Local Health Integration Network. Self-Management Toolkit: A Resource for Health Care Providers. Accessed Feb. 12, 2016.

This online toolkit provides instruction modules for clinicians on how to deliver self-management support (SMS) to patients. Three modules teach clinicians to: Assess how patients are managing their conditions; Assist patients in setting behavioral goals; and Assist patients with following action plans.

The toolkit of videos and materials is based on a manual by Gina Tomaszewski and Christina O'Callaghan titled "Self- Management in Theory and Practice: A Guide for Healthcare Providers."

South West Local Health Integration Network: http://www.selfmanagementtoolkit.ca/
How to use it: Users must register to access self-paced learning modules. The toolkit includes videos, quizzes, and an interface for users to share personal experiences using SMS. Users can track and save their progress in the modules and return at a later date.

SMS Training

Training materials have the primary function of helping healthcare professionals learn how they can implement primary care improvement concepts in a clinical setting. Some training materials can be used to fulfill individual continuing education credit requirements; others can be used in group settings to teach clinical teams about patient care improvement processes. Formats for training include videos, interactive Web pages, and printable training materials.

Title Source Summary
Improve Care with Patient Self-Management Support American Academy of Family Physicians

Citation: American Academy of Family Physicians. Improve Care with Patient Self-Management Support. Accessed Feb. 12, 2016.

This video explains why physicians should provide patient-centered, self-management support care and shows specific ways this can be done. The video demonstrates how to use motivational interviewing, health coaches, and group visits to improve patient care and practice efficiency.
Motivation: Behavior Change Counseling in Chronic Care Robert Wood Johnson Foundation

Citation: Huntington J, Ward D, Lessler D, et al. Motivation: Behavior Change Counseling in Chronic Care (Prepared by the University of Washington). Robert Wood Johnson Foundation, 2010. Accessed Feb. 12, 2016.

This resource contains a teaching guide that includes principles and techniques for communicating with patients about behavior change and chronic illnesses. It offers ideas for discussion in a training setting. An accompanying video demonstrates how a clinician could discuss behavior change with patients.

Links to video and teaching guide: http://www.son.washington.edu/pqe/patient-centered-video.asp

PDF of teaching guide: http://www.son.washington.edu/pqe/resources/TeachingBooklet2.pdf

Motivating Change Online Programs for Physicians The Permanente Medical Group

Citation: The Permanente Medical Group. Motivating Change Online Programs. Accessed Feb. 12, 2016.

This interactive tool uses the research-based "Brief Negotiation Roadmap" to teach clinicians how to conduct conversations with patients in a way that will increase their level of engagement in planning behavior changes. The tool also demonstrates common ways clinicians can unknowingly create barriers to patient engagement. Specific learning modules are provided for various categories of medical conditions.

Users must sign in using their name and e-mail address to gain access to the program. The training includes individual, interactive, and self-paced learning modules. It provides interactive case studies and gives immediate feedback about choices made by the user in case studies. The website includes printable health education tools that can be used in conversation with patients.

Motivating Patients to Change Behavior American Medical Association

Citation: American Medical Association. Motivating Patients to Change Behavior. Accessed Feb. 12, 2016.

This video from the American Medical Association defines principles of motivational interviewing and explains how motivational interviewing is different from traditional clinician-patient interactions. It provides examples of how clinicians may ask questions to help motivate patients to engage in behavior change.
Self-Management Strategies for Vulnerable Populations American Medical Association

Citation: American Medical Association, Portal of Geriatric Online Education. Self-Management Strategies for Vulnerable Populations. Accessed Feb. 12, 2016.

This video from the American Medical Association presents the challenges of providing care for patients with multiple chronic conditions, including elderly and racial and ethnic minority patients. The video introduces patient self-management support (SMS), and presents five steps to providing SMS. Steps include assessment, instruction, collaboration, implementation, and continuous support.
The Planned Care Visit MacColl Institute for Health Care Innovation

Citation: The Planned Care Visit. Improving Chronic Illness Care/MacColl Institute for Health Care Innovation. Accessed Feb. 12, 2016.

This video demonstrates a self-management interview with a diabetes patient as part of a planned care visit. The 34-minute video consists of three segments:

1. The Patient Experience, which shows clips taken before, during, and after the planned care visit (16 minutes)
2. The Provider Point of View, which depicts the clinical team's activities to provide self-management support (SMS) for the patient (5 minutes)
3. The Self-Management Interview, which shows collaborative goal-setting, action plan development, and problem-solving with a nurse and the patient (12 minutes)

The video examples of SMS implementation can be applied to patients with other chronic conditions.

Training Curriculum For Health Coaches UCSF Center for Excellence in Primary Care (CEPC)

Citation: University of California San Francisco, Department of Family & Community Medicine, Center for Excellence in Primary Care. Training Curriculum for Health Coaches. Accessed Feb. 12, 2016.

This site offers training and curriculum resources to explain the role of health coaches and train organizations on patient-centered health coaching.
Video on Coaching Patients for Successful Self-Management California HealthCare Foundation

Citation: California HealthCare Foundation. Video on Coaching Patients for Successful Self-Management. Accessed Feb. 12, 2016.

This video by the California HealthCare Foundation demonstrates patient-coaching techniques that clinicians and community health workers or educators can use to collaborate with their patients. Topics include effective communication, action plan setting, and adherence to medication plans. An action plan template is provided in English and Spanish.
Page last reviewed April 2017
Page originally created February 2016
Internet Citation: Self-Management Support Resource Library. Content last reviewed April 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/self-mgmt/self/sms_browse.html