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Self-Management Support

Because content in this area is still being developed, it is posted in "document" form — and these documents will be updated as the innovation work progresses.

 

In March 2005, The Robert Wood Johnson Foundation (RWJF) awarded IHI a grant to improve and spread the capacity of ambulatory care providers and those they serve to engage in productive, collaborative self-management support. This work will build on a Pilot Collaborative on Self-Management Support which implemented models of self-management in six pilot site practices. The practices worked to enhance patient-provider communication, the adoption of shared care plans and follow-up.

 

Going forward, 20 ambulatory care teams participating in the "New Health Partnerships: Improving Care by Engaging Patients" initiative (formerly known as Quality Allies) — supported by RWJF and the California HealthCare Foundation — will continue the work, involving patients and families in the design of care, leveraging IT to enhance self-management, and improving the business model for ambulatory care practices to implement self-management programs.

 

The content posted in this section will share what was learned in the pilot Collaborative, including the Chronic Care Model and the 5As Model of Behavior Change, both adapted for self-management support. New content and information resulting from the New Health Partnerships initiative will also be shared as that project gets underway.

How to Improve
Measures
Tools
Literature


How to Improve

This bibliography includes written and audiovisual materials related to patient- and family-centered care for maternity care, newborn intensive care, pediatric care, adult health care, end-of-life care, patient safety, education of health professionals, facility design, and leadership and organizational change.


The Pilot Collaborative on Self-Management Support adapted the 5 A’s Behavior Change Model from the tobacco cessation literature as a framework to highlight the processes and interactions essential to support the patient’s and family’s capacity to self-manage chronic illness.


This adaptation of the Chronic Care Model summarizes the basic elements for improving self-management support in health systems at the community, organization, practice and patient levels.


Measures

This measurement packet from the Pilot Collaborative on Self-Management Support describes measures developed to track three of the 5 A’s of behavior change.


Tools

A presentation providing a general overview of the 5 A’s and self-management support; developed by Bayer Institute for Health Care Communication, New Haven, Connecticut, USA.


A presentation describing the 5 A's of self-management support, that offers concrete patient-centered counseling techniques; developed by Bayer Institute for Health Care Communication, New Haven, Connecticut, USA.


A primer for implementing self-management support within a clinical setting; developed by Bayer Institute for Health Care Communication, New Haven, Connecticut, USA.


Assessment is the first of the 5 A's of behavior change. This bibliography contains a listing of journal articles, presentations, and tools (scales, surveys, questionnaires), along with the purpose, intended audience and availability of each.


The 5 A’s (Assess; Advise; Agree; Assist; Arrange) give providers an organizing principle for understanding the steps that support patients in behavior change. This bibliography includes a description of the 5 A’s in practice, methods for applying them to physical activity counseling in health settings, and numerous other resources.


Group medical appointments, also called group visits, are an increasingly popular and effective way to provide peer support, medical education, and timely access to providers. This bibliography contains journal articles, as well as instruction manuals and videos.


This bibliography contains articles and other resources describing quality improvement in health care systems, in general, and more specifically, indications for improvements in chronic care using the Chronic Care Model.


Behavior change is incremental and benefits from ongoing follow-up and coaching. The articles included in this bibliography provide information on the efficacy of behavior change follow-up and how some systems have succeeded.


This bibliography provides information on theory-based patient-provider communication and empowerment, particularly in support of behavior change. Included are articles, books and chapters, websites, presentations, and assessment tools.


This bibliography includes journal articles and an assessment tool focused on problem-solving skills and strategies for self-management support.


This bibliography contains the basic evidence base for self-management support, including more in-depth information on delivery of self-management support in primary care and community settings.


The effectiveness of behavioral counseling and patient-provider interactions to enhance self-management are central topics when examining behavioral risk factors. This bibliography lists journal articles, books and chapters, presentations, and training materials designed to assist providers in supporting behavior change.


Truly patient-centered care requires overcoming health disparities due to cultural, racial, or ethnic differences between provider and patient. Materials listed in this bibliography include journal articles, books and chapters, videos, websites, and assessments and surveys.


This bibliography contains journal articles, books and chapters, presentations, websites, and other materials to facilitate the integration of an expanded range of community services into health care to support people in managing their chronic conditions.


The articles and other resources listed in this bibliography represent the growing evidence base for the implementation of effective self-management support interventions in health care delivery systems, including tasking models, patient education, and training of health professionals.


Presenting a business case for quality is a major barrier for many systems in implementing self-management support. This bibliography lists journal articles, a book, and a presentation that all discuss the financial implications of implementing quality improvement.


This bibliography contains journal articles describing the use of interactive technologies in direct care delivery, as well as population-based care, consumer health informatics, and population-based case management.


"Re-Aim" is a systematic way for researchers, practitioners, and policy makers to evaluate health behavior interventions, and it can be used to estimate the potential impact of interventions on public health. This bibliography includes journal articles, a website, and a presentation.


This collection of information, tools, and resources can be a useful reference for patients who want to better manage their condition or change behaviors. The bibliography includes books and chapters, websites, instruction manuals, and assorted materials.


Literature

A listing of seminal literature, both condition-neutral and -specific, that can be used as a concise self-management support bibliography.