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Educate and Experiment
Outcome: A trained team with experience
Time to Complete: Up to several months
Pick the skill that you'd like to tackle first. Decide how to educate yourself and your team, and then provide training, test the process with a small group of patients, evaluate and adjust as needed, and repeat until you and your team are satisfied with the result. Use the same approach for the other key skills.
Eventually, you and your team should have the training and experience needed to determine how PSMS can best be integrated into your practice.
PSMS Key Skill #1: Assessing self-management abilities
A good first step with each patient is to assess his or her self-management abilities. This will help you understand the patient's situation and potential obstacles to self-management that the patient may have to overcome.
These questions may help you or your staff make this assessment (3-page PDF; About PDFs). You also could search American Family Physician for assessments related to specific chronic conditions.
Having a family member or caregiver present during the assessment can be valuable. He or she may provide more information or a different viewpoint about the patient's abilities.
Assessing the patient's caregiver may prove helpful as well. The American Family Physician article, Caregiver Care, provides extensive information on caregiver assessment and resources.
PSMS Key Skill #2: Using motivational interviewing
Motivational interviewing (MI) is patient-centered, goal-oriented counseling to motivate behavior change. Originally developed for use by substance abuse counselors, MI also works well in the family medicine office and other settings.
All care team members can use MI. It's especially helpful when the patient hesitates to set a self-management goal.
MI is not an expert-recipient conversation. Instead, it's a collaborative conversation between the care team member and the patient that explores and seeks to resolve the patient's ambivalence about making a change. The intent is to help the patient be ready to select his or her own self-management goal.
The care team member uses the OARS technique— open-ended questions, affirmations, reflective listening, and summaries— to help the patient identify, examine, and resolve ambivalence about changing behavior.
These general principles behind MI should be kept in mind while using the OARS technique:
- Express empathy. When patients feel they're understood— when they realize you're interested in their problems and ideas— they're less likely to feel defensive and more likely to be open to anything you tell them.
- Support self-efficacy. This is the key component of PSMS. Make patients responsible for choosing the change they want to make. To help them believe that change is possible, remind them about skills they already have and any past successes. If other patients have made the same change, share those examples.
- Roll with resistance. When patients raise barriers to change, don't argue. Instead, encourage them to find their own solutions. If they don't want to set a self-management goal during a visit, drop it— they may come back the next time ready to work on it.
- Develop discrepancy. Motivation for change happens when patients see the discrepancy between where they are and where they want to be. Helping them realize that their current behaviors are taking them in the wrong direction helps develop discrepancy.
- The Family Practice Management article, Encouraging patients to change unhealthy behaviors with motivational interviewing, describes the structure of MI and how it can be used in the family medicine office.
- The AAFP video, Improve Care with Patient Self-Management Support, includes an example of MI.
- The Motivational Interviewing website offers extensive MI information and training materials.
- The Iowa Chronic Care Consortium's health coach training programs include MI training.
Although setting a self-management goal during the physician visit is an important first step, very few patients will attain their goals without more help. Health coaching provides that help.
Health coaching gives patients the information, skills, tools, and confidence needed to reach their self-management goals. Health coaching tasks include:
- Reviewing what occurred during the physician visit, to make sure the patient understands and agrees
- Working with the patient to develop a written action plan for achieving the self-management goal
- Encouraging the patient to share the action plan with family members to get their support
- Educating the patient about his or her chronic disease
- Teaching disease-specific skills, such as blood glucose monitoring
- Helping the patient cope with the emotional impact of chronic disease
- Providing information on community programs that could be of assistance
- Calling the patient a few days after the visit to check progress, problem solve, and provide encouragement
- Always asking questions to learn the patient's perspective and keep the patient engaged
The video, Coaching Patients for Successful Self-Management, which can be accessed on the California HealthCare Foundation's website, shows an example of action planning.
Everyone on the care team could provide health coaching, but some practices go a step further and assign the health coach role to a specific team member, such as a nurse or medical assistant. In some instances, the health coach is a community health worker, or even a patient who has the same chronic condition and has been trained in health coaching.
No matter who provides health coaching, make sure it is provided in a culturally and linguistically appropriate manner. The National Center for Cultural Competence has many helpful resources.
Learn more about health coaching and health coach training from these resources:
- The AAFP video, Improve Care with Patient Self-Management Support, includes information on health coaching.
- The Family Practice Management article, Health coaching for patients with chronic illness, describes the roles of the health coach and two models for using health coaching in the practice.
- For health coach training resources, visit the California HealthCare Foundation's list of recommended self-management support training materials.
- The Iowa Chronic Care Consortium offers health coach training.
With conditions such as diabetes and hypertension, home monitoring helps patients track how they're doing. But the results of monitoring are useful only if the patient knows what to do in response. Helping the patient develop the ability to conduct home monitoring successfully is a component of PSMS.
Before suggesting home monitoring, consider what you know about the patient's self-management abilities and the abilities of any caregivers, and then decide if home monitoring is likely to work.
If it is likely to work, suggest home monitoring to the patient as a self-management goal. If the patient hesitates, use motivational interviewing to explore ambivalence and help the patient move toward change.
If the patient agrees to try home monitoring, help him or her prepare an action plan (1-page PDF; About PDFs). Ask the patient to think of ways to overcome obstacles to monitoring that may arise. One obstacle may be the cost of supplies (e.g., lancets and test strips for blood glucose monitoring). Ask the patient if cost is an issue, and if it is, provide information about community resources or patient assistance programs that may help.
Offer to help the patient choose appropriate, accurate equipment for home monitoring. Next, provide training.
- Show how to use the monitoring equipment, then coach as the patient does it.
- Provide specific, written instructions for when to monitor and how to understand and act on the readings. Ask the patient to bring a log of readings (or, in the case of blood glucose monitoring, to bring the meter) to the next office visit so that data can be retrieved.
PSMS Key Skill #5: Engaging family and caregivers in the self-management care plan
The patient doesn't live in a vacuum. When possible, involve family members or other caregivers in the self-management process. They can boost the patient's motivation, help the patient remember information, and contribute to positive lifestyle changes at home— all of which can lead to better outcomes.
When you and the patient create an action plan for achieving a self-management goal, list the caregiver or family members as supporters who could help the patient accomplish the goal. Encourage the patient to show the action plan to supporters and enlist their help.
Bringing it all together
Once you and your care team have used the key skills of PSMS with small groups of patients, you'll be ready to determine the best way to integrate PSMS into the office visit workflow. (See Establish a Workflow.)
What You Will Need
- Decision-making authority
- Time to train yourself and the team and to select tools
- Money, if the training method you select has a cost
- Time to experiment with small groups of patients
Consider using this action plan form when working with the patient on the plan for achieving a self-management goal. (1-page PDF; About PDFs),
Where to Go for Help
Learn more about motivational interviewing by reading the Family Practice Management article, Encouraging Patients to Change Unhealthy Behaviors With Motivational Interviewing.
Learn about health coaching from another Family Practice Management article, Health Coaching for Patients With Chronic Illness.
The AAFP video, Improve Care with Patient Self-Management Support, discusses health coaching and offers an example of motivational interviewing.
The Motivational Interviewing website is a good source of information and training materials.
The California HealthCare Foundation's website offers a list of recommended PSMS training materials, which includes health coach training resources. The video, Coaching Patients for Successful Self-Management, which is on the list, shows an example of action planning.
Another source of health coach training is the Iowa Chronic Care Consortium.
The National Center for Cultural Competence is a good source of information on cultural and linguistic sensitivity.