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Steps for Improvement (7): Self-Management Support

"The individual's ability to manage the symptoms, treatment, physical and social consequences and lifestyle changes inherent in living with a chronic condition". 
- Barlow, et al., Patient Education and Counselling, October 2002
What is Self-Management Support?
Supporting patients in the tasks of managing their own chronic condition(s) calls for more than education, in which patients gain knowledge about their condition. Patients need to have the skills and confidence to effectively manage the condition on their own.

Researchers have described three categories of tasks that patients with chronic conditions perform: the first is managing the illness (such as learning to take medications and monitor the condition); the second is to carry on normal roles and activities; and the third is to manage the emotional impact of the illness. Since every patient with a chronic condition is a self-manager, responsible for most of his or her own care, support of self-management is an ongoing activity for the health care team.

The goal of self-management support is to assist and sustain the patient's ability to engage in self-management behaviors that fit within their own life patterns. The creation of a personal action plan is an important way in which providers can support their patientsí self-management goals. Another key skill is to help patients learn to solve problems.

Getting Started
Prepare to introduce the concept of self-management to the patient. Help the patient understand that they are the managers of their health with your assistance. Help the patient determine his or her own priorities. Ask about and understand your patient's perspective: about health beliefs, living circumstances, problems, etc.

Asking about these issues in the interest of understanding the patientís perspective will allow the two of you to establish goals based on patient wants, as opposed to those arising from clinical priorities alone. (NOTE: Once you have the patient achieving success in setting their own personal health care goals, you can weave in your desired goals over time.) Assess the patientís confidence in carrying out a plan, and be sure to follow-up to help them achieve the goal and problem-solve barriers.

It is recommended that the physician, nurse practitioner or physicianís assistant introduce this concept as a prescription for care to increase acceptance by the patient. The provider may then want to refer the patient to someone who can assist with goal setting.

Collect data about goals set and achieved, for use in the next visit. The patient encounter form from the registry (or a structured encounter form you've made) is critical to successful data capture. Make sure these data are entered in the registry or are easily accessible for use at the next visit.

After agreeing on when and how you and your patient will proceed with the established self-management goals, enter the information in the written patient plan. Also agree on an interval between planned visits, based on clinical need and patient preference. Ensure that follow-up to all clinical and self-management tasks is part of your daily practice of care, and that the patient receives a copy of the plan.

Building Self-Management Support Into the Planned Care Visit: Making a Specific Plan
The plan should contain all of the following steps:
  • Exactly what are you going to do?
    How will you eat less, how far will you walk, what meditative technique will you practice?
  • How much will you do?
    Will you walk 2 blocks walk for 20 minutes, not eat between meals for 2 days, practice yoga for 10 minutes?
  • When will you do this?
    Will you do this before lunch, in the shower, when I arrive home from work?
  • How often will you do the activity?
    Itís recommended to plan to do something three or four times a week. If you do more, so much the better but the goal is to do your activity often enough to be successful, and yet not feel pressured on a daily basis.
  • Anticipated barriers
    Help the patient imagine what might get in the way of their plan.
  • Potential solutions for barriers
    Have the patient come up with ideas that might help them overcome the barriers.
  • Follow-up plan
    When, where and how will you check in with the patient about their experience with the plan.
  • Confidence rating
    On a scale of 1-10 (with 1 being no confidence that the plan can be completed to 10 being absolutely certain that they can complete the plan), have the patient rate their confidence level.
When implementing an action plan, the start slowly and build successes. If they can walk only for one minute, suggest walking one minute once every hour or two, not with walking a mile all at once, start the program. If the goal is to lose weight, set a goal based on existing eating behaviors, such as not eating after dinner, rather than drastically changing eating patterns.

Tips for Creating a Successful Action Plan
  • Begin with something the patient wants to do
  • Make the goal reasonable (something the patient can reasonably expect to be able to accomplish this week)
  • Strive for a change that is behavior-specific (losing weight is not a behavior; not eating in the evenings while watching television is a behavior)
  • Ensure that the plan answers these questions: what; how much; when (think about the day/the week Ė which days, what times, etc.); how often?
  • Start when the patient has a confidence level of 7 or greater (this is the belief that they can, and will, complete the entire contract) .
Goals Versus Behavior-Specific Changes
Keep in mind the differences between a healthy change, a goal that is set to reach that change, and the behavior required to attain that goal.
Problem-Solving Techniques
It can be helpful to remind patients that change often takes time and effort. Hearing a health care provider reiterate that self-management can require persistence, and that success is possible Ė even when obstacles are encountered - can be just what the patient needs when the going gets a bit rough. The following method has been shown to help patients find solutions to problems.
  • Identify the problem
    Help the patient get to the root of the issue. For example, is it that they have problems maintaining a diet when they eat out, or their family doesnít understand their wishes to eat a healthier diet?
  • List ideas to solve the problem
    Help the patient come up with many ideas, some they have tried before to some that may seem ridiculous, and to come up with a list of ideas that might work.
  • Choose one method to try
    Out of all the options listed, help the patient choose one, or a combination of ideas that they think will work for them.
  • Try it for 2 weeks
    Encourage patients to give each idea a good trial period to see if it will work.
  • Evaluate the results
    After the patientís given the idea a fair trial, assess the outcome.
  • Try another idea if the first one doesnít work
    Have the patient return to their list of ideas and try another.
  • Locate other resources
    Resources can be friends, family, members of their health care team, or a community link such as the public library or a health fair.
  • Accept that the problem may not be solvable right now
    Remind the patient that if the solutions they came up with this time havenít worked, that it doesnít mean that other solutions wonít be effective at another time, or that different problems canít be solved using this solution. Encourage them to keep trying; do your best to foster hope and persistence.
Much of the content above has been adapted from Lorig, et al, Living a Healthy Life with Chronic Conditions, Bull Publishing Company, 2000.† For an easy-to-read primer on doing self-management support in practice, read this unpublished manuscript by Tom Bodenheimer, MD [DOC].