Patient self-management support (PSMS) is a system of care in which the care team works collaboratively with patients and their families to improve health outcomes, instead of the physician dispensing advice, writing prescriptions, and hoping that patients will "comply."
PSMS shifts the care paradigm from telling patients what to do, to asking patients what they are willing to do and working collaboratively with them. Keep in mind that patients already are self-managing their conditions (they're living with the conditions 24/7)but they're often not self-managing well. In the new paradigm, the care team uses the techniques and tools of PSMS to help patients develop the motivation, knowledge, skills, and self-confidence they need to do a better job, which leads to improved clinical outcomes.
At each physician visit, the patient and physician jointly set the agenda, which engages the patient immediately. They have a collaborative conversation about the agenda items and then develop the treatment plan together. The plan includes a realistic self-management goal that the patient has suggested.
Next, another care team member (usually the medical assistant or nurse, or someone designated as a health coach) helps the patient develop a written action plan to take home. The action plan lists speciﬁc things the patient plans to do to move toward meeting the goal; ways to overcome obstacles that may arise; and contact information for potentially helpful community programs. The plan also includes the date and time for a follow-up visit.
The medical assistant, nurse, or health coach calls the patient between visits to check progress and offer encouragement.
Success with achieving realistic, incremental goals builds the patient's self-confidence, leading to more success, better daily decisions, and better outcomes. Patient success also energizes the care team and improves morale and job satisfaction.
PSMS can be used with patients across the continuum, from those who have no health problems to those with the most serious illnesses. It's especially useful for patients who have chronic conditions and for improving medication adherence.
PSMS may improve clinical outcomes for patients with chronic conditions, but change is necessary to make it work. Are you ready to:
Notify staff who will serve with you on the pilot project team. Set the date for the first team meeting.
At the next all-staff meeting, introduce the concept of PSMS and announce the upcoming pilot project.
These talking points(1 page PDF) may help you discuss PSMS with others in the practice, or you can create your own talking points.
Consider showing the AAFP video, "Improve Care with Patient Self-Management Support" to educate others about PSMS.
Outcome: An informed practice and a project team
Time to Complete: Two months
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Assess Readiness: Patient Self-management