Set and Document Self-Management Goals Collaboratively with Patients Who Have Chronic Conditions

Improving Chronic Care: Self-Management Support
  1. Identify self-management tools, including the following:
    • An action plan that includes goals and describes behavior (e.g., increasing activity by walking 15 minutes, 3 times per week)
    • A review of the patient's confidence level (e.g., on a scale of 1 to 10, how confident are you that you can meet your goals?)
    • A follow-up plan
  2. Review the tool with the multidisciplinary team, including all those who will be involved in its use-physicians, nurses, volunteers, promotoras, etc.
  3. Test the tool with a few patients and revise as indicated. Retest with additional patients and different populations.
  4. Establish and/or review goals with patients as part of the planned visit and follow-up.
  5. Assess patients' skill, understanding, and confidence in managing their disease.
  6. Give patients a copy of goals, and place a copy in the chart.



  • Make sure staff are comfortable with the self-management philosophy and trained in behavioral techniques to support patients.
  • Train lay workers to set goals with patients.
  • Create a system to communicate goal changes with other providers caring for patients (pharmacy, nursing, lay community workers, etc.) so that they can reinforce them. For example, write new goals (e.g., "walk 15 minutes, 3 times per week") on a prescription pad and give to patients to show to other providers.
  • Develop a process and train providers so that the self-management process can fit in the 15-to 20-minute visit, if necessary. It does not require a long session.
  • Work with patients to define goals.
  • Don't prescribe goals or use checklists.
  • Include family and caregivers in setting goals.
  • Use groups for patient goal setting.
  • Have medical assistants ask patients about goals when taking vitals.
  • Have providers review goals with patients briefly.
  • Assign staff to arrange follow-up with patients.
  • Document goal setting in the registry. Include some specifics of the goal and the date(s).

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