1. Identify high leverage self-management support elements and activities to incorporate
into the practice.
2. Align the self-management support program with Patient-Centered Medical Home
initiatives and metrics
BCBSM PGIP-PCMH - The goal of the self-management support initiative is to enable patients with chronic conditions to actively and effectively manage their conditions with the support of an educated clinical care team. The clinical care team is expected to have at least one member with education and training in self-management concepts and techniques and the ability to share that knowledge with other staff members. Additional expected capabilities involve the provision of self-management support to patients with chronic conditions, goal setting for patients and related support, systematic follow-up to review action plans, goals, and provide supportive reminders, utilization of experience and satisfaction surveys, and pursuit of formal training for designated staff member.
NCQA – Elements for certification as a PCMH include actively supporting patient self-management including written care plans, appropriate written materials for patients and referral to community resources (must pass element) and assessing language preference and other communication barriers.
3. Make a list of self- management services you will offer and identify which health plans, if
any, cover the services. Develop a process for documentation and billing for the services.
4. Consider how interactions between health care team members and patients may need to
change in order to support patient self management and how that might impact the health
care provider/patient relationship .
5. Implement an education and training program for providers and staff.
Education and Training: The Self Management Toolkit combines videos and tools to provide step by step instructions for office staff on providing self-management support during a visit. The site was created by a panel of international experts in the field and is based on Self- Management in Theory and Practice: A Guide for Healthcare Providers by Gina Tomaszewski and Christina O'Callaghan. Users must register to use the site, but there are no fees
6. Locate existing self-management tools and resources.
7. Examine current practice staff roles and identify needed roles and responsibilities to
implement self-management support. Modify/clarify roles and responsibilities as necessary
with policies, protocols and standing orders.
8. Consider engaging a Medical Practice Coach to assist with practice transformation.
9. Create a plan to document and evaluate your implementation of patient self-
management elements and activities.