Applicable to PCPs and specialists. When patient is co-managed by PCP and specialist, roles must be clearly defined regarding which provider is responsible for leading self-management support activities and which provider is responsible for reinforcing self-management support activities.

To receive credit for a self-management support capability, basic self-management support delivered in the context of office visits must be available to all patients. Advanced self- management support, delivered by trained care managers in the context of provider-delivered care management services, is expected to be available only to those members who have the provider-delivered care management benefit. 

11.1

Clinician who is member of care team or PO staff person is educated about and familiar with self-management support concepts and techniques and works with appropriate staff members at the practice unit at regular intervals to ensure they are educated in and able to actively use self-management support concepts and techniques.

PCP and Specialist Guidelines:

1. The intent of this capability is to actively empower the staff within the practice unit to incorporate self-management support efforts into routine clinic process.
2. Regular intervals are defined as a minimum of once per year
   1. New staff must be trained at time of entry to practice
3. Self-management support uses a team-based, systematic, model-driven (including behavioral and clinical dimensions) approach to actively motivating and engaging the patient in effective self-care for identified chronic conditions; must extend beyond usual care such as encouragement to follow instructions
4. Level, type, and intensity of training, education, and expertise may vary, depending upon team members’ roles and responsibilities in the Practice Unit
   1. Education must be substantive and in-depth and focus on a particular model of self management support and not consist of only a brief introduction to the concept.
      Recommended sites for more information include:
      • IHI Partnering in Self-Management Support: A Toolkit for Clinicians
      • Self-Management Support Information for Patients and Families
      • California Health Care Foundation Self-Management Support training materials
      • Flinders Self-Management Model
      • Motivational Interviewing
5. Education of practice unit staff members may be provided by PO staff person if the PO staff person has adequate time to provide comprehensive, meaningful education; otherwise, practice unit is responsible for identifying a member of the practice’s clinical care team to receive education in self-management support concepts and techniques 
6. Appropriate team members should have awareness of self-management concepts and techniques, including:
   1. Motivational interviewing
   2. Health literacy/identification of health literacy barriers
   3. Use of teach-back techniques
   4. Identification of medical obstacles to self-management
   5. Establishment of problem-solving strategies to overcome barriers of immediate concern to patients
   6. Systematic follow-up with patients

11.2

Self-management support is offered to all patients in the patient population selected for initial focus (based on need, suitability, and patient interest)

PCP and Specialist Guidelines:

1. Self-management support is assisting patients in implementing their action plan through face-to-face interactions and/or phone outreach in between visits.
2. Self-management support services may be provided in the context of a planned visit
3. An action plan is a patient-specific goal statement that incorporates treatment goals including aspects of treatment that involve self-management. It is not an action step; it is a goal statement.
4. Physicians may provide self-management support within the context of E&M services

11.3

Systematic follow-up occurs for all patients in the patient population selected for initial focus who are engaged in self-management support to discuss action plans and goals, and provide supportive reminders

PCP and Specialist Guidelines:

1. Follow-up may occur via phone, email, patient portal, or in person, and must occur on a timely basis appropriate to the patient’s needs, either at the time of visits if they are frequent, or in between office visits if they are infrequent.

11.4

Regular patient experience/satisfaction surveys are conducted for patients engaged in self management support, to identify areas for improvement in the self-management support efforts

PCP and Specialist Guidelines:

1. Surveys may be administered electronically, via phone, mail, or in person
2. Results must be quantified, aggregated, and tracked over time
3. Self-management support survey questions may be added to regular patient satisfaction surveys providing sampling is structured to ensure adequate responses from those who actually received self-management support services
4. If survey results identify areas for improvement, timely follow-up occurs (e.g., self management support efforts are systematized to assure they are available on a timely basis to all patients for whom they are appropriate)

11.5

Self-management support is offered to multiple populations of patients within the practice’spatient population (based on need, suitability and patient interest)

11.6

Systematic follow-up occurs for multiple populations of patients within the practice’s patient population who are engaged in self-management support to discuss action plans and goals, and provide supportive reminders

PCP and Specialist Guidelines:

1. Follow-up may occur via phone, email, patient portal, or in person, and must occur on a timely basis appropriate to the patient’s needs, either at the time of visits if they are frequent, or in between office visits if they are infrequent.

11.7

Support and guidance in establishing and working towards a self-management goal is offered to every patient, including well patients

PCP and Specialist Guidelines:

1. Self-management goal is developed collaboratively with the patient and is specific and reflective of the patient’s interests and motivation

11.8

At least one member of PO or practice unit is formally trained through completion of a nationally or internationally-accredited program in self-management support concepts and techniques, and regularly works with appropriate staff members at the practice unit to educate them so they are able to actively use self-management support concepts and techniques.

PCP and Specialist Guidelines:

1. Training for self-management techniques should include:
   1. Motivational interviewing
   2. Health literacy/identification of health literacy barriers
   3. Use of teach-back techniques
   4. Identification of medical obstacles to self-management
   5. Establishment of problem-solving strategies to overcome barriers of immediate concern to patients
   6. Systematic follow-up with patients
2. Practices should seek structured information/approaches/processes, which can be from any legitimate source
3. Examples of training programs that meet the criteria are available from the PGIP Care Management Resource Center
   1. Such programs must be sufficiently robust that they provide ample opportunities for learners to practice new self management support skills with individualized feedback as part of the practice experience.