Use an incremental approach to ease your care team into patient self-management support (PSMS). To begin, review the information below about key skills used in the PSMS process. Some are relatively easy to institute, while others require more training and practice. Some also require the selection of tools to use.
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.
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(2 page PDF) may help you or your staff make this assessment.
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.
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:
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:
Action planning is one of the most important health coaching tasks listed above. Consider using an action plan form(1 page PDF) when you institute health coaching in your practice. Have protocols in place to ensure that the patient's action plan is checked at each visit.
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.
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. 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.
Set a date and time for a follow-up phone call to discuss how home monitoring is working.
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.
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.
Difficulty: Moderate; requires training and practice to develop new skills
Outcome: A trained team with experience
Time to Complete: Up to several months
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