Help patients understand their central role in managing their conditions and that the entire health care team is there to help.
Make time for self-management by gathering clinical and patient experience data in the chart.
Ask patients to bring questions and concerns and health monitoring information.
Collaboratively develop a visit agenda with the patient and family, handling as many concerns as possible, and plan return visits as appropriate.
Engage the entire practice team in supporting patients, use “warm handoff” introductions, and explain team member roles to patients.
Ask about patient goals to improve their health and help them make action plans that build confidence in their ability to reach these goals.
Use “ask-tell-ask” to provide just the right information at just the right time and “close the loop” to ensure patients know how to use the information.
Prepare a written care plan or visit summary that includes goals and action plans to ensure patients and families know what to do when they leave the visit.
Use group medical appointments, peer-led support groups, or patient education classes to provide opportunities for patients to share experiences and support.
Organize follow-up support to help patients sustain healthy behaviors between visits
Extend care into the community by linking patients to community programs.
Designate and train a lead coach for self-management support who will support ongoing staff development of skills.
Assign responsibility for self-management tasks to all team members, extending the work out from the physician.
Use daily team huddles to review the schedule of patient charts, anticipate care needs, and enhance the flow of care.
Schaefer J, Miller D, Goldstein M, Simmons L. Partnering in Self-Management Support: A Toolkit for Clinicians. Cambridge, MA: Institute for Healthcare Improvement; 2009. Available at: www.IHI.org
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