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Patient Self-Management

Additional Information

Learn about Qualis Health's efforts to promote patient self-management as one component of:


What is self-management?

A patient’s health-impacting choices (medication acceptance, food selection, etc.) are often referred to as self-management. Patients with chronic illness are self-managers for a lifetime, with or without professional support. According to the CDC, at least 80% of older Americans are living with at least one chronic condition, and 50% of them have at least two conditions.

Each patient faces unique challenges to becoming confident and skilled at self-management. Many issues—including health literacy, advanced age, access to healthy food, and changes in functional skills due to illness—present risks for successful self-management.
 

Recognizing the partnership between providers and patients

The NCQA and AAFP definitions of ideal primary care describe patients as “working in partnership with their doctors and other healthcare professionals” and “active participants in their own health.”

This becomes particularly important with chronic disease care, where successful prevention of expensive, adverse outcomes is dependent not just on receiving the correct evidence-based interventions from a healthcare provider, but also on the daily decisions a patient makes about health management choices.

The role patients play in their own health is critical to improved health—and while this is intuitive, practices that don’t recognize their role as a partner in encouraging healthy choices may miss a powerful opportunity for improved outcomes.
 

Rewarding outcomes

Helping patients develop and sustain healthy behaviors can be very rewarding. Being supportive of small, incremental changes will help patients experience bigger successes over time.

In addition, taking the proactive stance to put self-management techniques into practice now will better position organizations for future reimbursement models.
 

Detailed information and examples

Two excellent resources, the Institute for Healthcare Improvement's Partnering in Self-Management Support: A Toolkit for Clinicians and the California Healthcare Foundation's Helping Patients Manage Their Chronic Conditions can be used to help elicit patients' concerns and preferences while developing a shared agenda toward self-management. The care team (including the medical assistant) can be trained to inquire about progress and record that information in the EHR.

Try motivational interviewing to activate the patient during the visit, and brush up on the various stages of readiness for behavior change to tailor approaches to the patient’s current motivational level.

Actively involve patients in discussion using the Teach Back method, which has been shown to improve patient comprehension and recall.

To help patients define and achieve goals related to improved management of chronic disease, quitting smoking, losing weight, or other lifestyle changes, guide them through the "My Health Goal" worksheet and develop a follow-up plan to monitor progress.

Make sure to provide helpful after-visit summaries to patients. For help in designing and refining EHR-generated versions, see the WIREC whitepaper Providing Clinical Summaries to Patients after Each Office Visit: A Technical Guide.

Read an interview with a patient after she had received coaching to become more activated in her own healthcare.

Read how one primary care practice increased patient activation by using a pre-visit summary.

Activated patients are less likely to be readmitted after a hospital stay. Healthcare providers and community educators are invited to use Qualis Health's "Know Before You Go" slide set to educate patients and families about hospital discharge processes, and what they can do to prepare for a safe transition.